Melanoma Surgery Update James R. Ouellette, DO FACS Premier Health Cancer Institute Wright State University Chief, Surgical Oncology Division
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1 Melanoma Surgery Update 2018 James R. Ouellette, DO FACS Premier Health Cancer Institute Wright State University Chief, Surgical Oncology Division
2 Surgery for Melanoma Mainstay of treatment for potentially curative melanoma Progress over several decades to less surgery being more effective Primary tumor margins Lymph node basin Surgery can be effective for metastases 2
3 Resection with Primary Closure 3
4 4
5 5
6 Assessment of Potential Malignant Skin Lesions History: sun exposure, personal hx, immunosuppression, transplant, radiation FHx Lesions: size, change Constitutional symptoms PE: including mucosal membranes, nodules, LNNs 6
7 ABCDE s 7
8 Biopsy of Skin Lesions Excisional biopsy Incisional biopsy, punch biopsy Shave biopsy Biopsy on extremity: long axis of extremity 8
9 Staging of Melanoma Risk of metastasis: ulceration, depth >4mm, mitotic index 9
10 AJCC Staging Survival 8 th Edition 10
11 Surgical Treatment of Primary Wide margins do not effect biology Overall survival and disease free survival was not impacted by wider margins Local recurrence decreases survival Factors predictive for LR: anatomic site, thickness, ulceration and age > 4mm: 13% risk of LR Few data to support wider excision Bedrosian, Surg Clin N Am
12 Summary for Excision Margins Tumor thickness Melanoma in situ Margin 0.5 cm < 1 mm 1 cm 1-2 mm 1-2 cm 2-4 mm 2 cm > 4mm 2 cm* * No randomized prospective trials for this cohort 12
13 The Lymph Node Discussion Complete LND dissection: introduced by Snow 1892 Therapeutic benefit of CLND of clinically negative LNNs has never been proven Routine CLND does not impact survival WHO trial #14: may be a survival benefit to CLND in patients with microscopic positive LNNs Identification of regional LN status has become exceedingly important for determining prognosis and adjuvant therapy 13
14 CLND vs SLN Only 20-30% of patients are LN + CLND: high cost, morbidity, low yield of + LNs Alternative: SLN for clinically negative LNs Standard staging procedure for stage I-II melanoma NPV of SLN approaches 98% thickness + LNN% 0-1mm >4 35 Gershenwald, J Clin Oncol
15 The Sentinel Lymph Node Lymphatic mapping: 1800s by Sappey SLN: 1977 by Cabanas Lymphatic mapping/sln: introduced by Morton 1992 Primary site drains through a specific channel on an individual basis to a specific lymph node SLN Dual and unexpected lymphatic patterns (32% trunk, 60% neck) 15
16 Lymphoscintigraphy Intradermal injection of 99mTC sulfur colloid sc around the primary melanoma or biopsy wound Filtered with 0.2 micron filter, microci in 4ml NaCl Dynamic images by scintillation camera Lymphatic basins at risk are identified Skin overlying the highest uptake (SLN) is marked Essner, Leong; Surg Clin N Am 2003 Augsburg consensus
17 17
18 Intraoperative Mapping Technique cc Lymphazurin injected intradermally around the primary melanoma 5-15 min to reach the SLN Handheld gamma probe: identify area of greatest activity 2-3cm incision 18
19 19
20 20
21 Recommendations ASCO-SSO 2018 Thin Melanomas No SLN for <0.8mm (unless Ulcerated) SLN recommended >0.8mm Intermediate SLN recommended for (>1 to 4mm) for staging Thick melanomas SLN recommended after d/w patient 21
22 Role of CLND vs Observation Both are options We are seeing more melanoma surgeons foregoing CLND (since MSLT II pub) MSLT-II and DeCOG-SLT Both RCT Excludes high risk features No difference in Melanoma Specific Survival in CLND vs Obs groups 22
23 CLND vs Obs High risk features (MSLT II exclusion factors) Extracapsular extension Microsatellitosis >3 LN >2 involved nodal basins Immunosuppression 23
24 Close Observation 24
25 Additional Advances of Interest to Melanoma Surgeons Immunotherapy MIS groin dissection Less invasive approach, similar lymphedema, less infections Talimogene Laherparepvec (Imlygic) Oncolytic viral therapy- direct injection for unresectable disease Melanoma Decision Dx GEP predicts metastasis free survival 25
26 QUESTIONS? 26
27 27
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