Management of Cutaneous Melanoma of the Head and Neck and a bit about SCCA/BCC. Irvin Pathak

Transcription

1 Management of Cutaneous Melanoma of the Head and Neck and a bit about SCCA/BCC Irvin Pathak

2 Objectives Risk Factors Biopsy techniques Current surgical treatment Current Status of Adjuvant Therapies

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4 Epidemiology Peak incidence is age Lifetime risk Canada Men 1/59 Women 1/73 Australia 1/20

5 Environmental Risk Intermittent intense exposure in childhood Recreational sun exposure more important than occupational sun exposure Two pathways chronic sun exposure and occupational sun exposure may be more important in head and neck melanoma

6 Relative Risk of Developing Melanoma Changing nevus 500x > 50 normal moles 4x >11 moles on right arm 10 x One atypical mole 2x Previous Melanoma 10x Family Hx 2-10x

7 Physical exam ABCDE asymmetry, border, color, diam> 6 mm, evolving ugly duckling 40% of normal and 40% of dysplastic moles are histologic dysplasia

8 Biopsy everything!

9 Biopsy of pigmented lesions Shave and punch biopsies very unhelpful Excisional biopsy with 1 mm margin Like the keel of a boat

10 Never take out the suture of a biopsy proven skin cancer

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12 Or at least draw picture with measurements from landmarks

13 Sydney Melanoma Unit In the 1960 s melanoma was a rare disease with very poor prognosis In Australia, 80% of patients presented with advanced disease at that time Survival of patients with melanoma was < 20%

14 Breslow Thickness (1970) and <1mm 95% Survival 1-2 mm 85% 2-4 mm 75% >4 mm 30%

15 Treatment of Primary Melanoma The standard of excision for 50 years was one inch of skin and another inch of subcutaneous fat - Handley 1907 Several randomized trials have provided a rationale for smaller radial margins

16 Treatment of Primary Melanoma In situ melanoma 5mm (case reports) Thin melanoma (<1mm) - 1 cm margin Intermediate ( 1-4 mm) - 2 cm margin Thick melanoma (> 4mm) - 2 cm margin

17 Risk Stratification Based on Melanoma Thickness Regional metastases Distant metastases 10 0 < >4.00

18 Elective Lymphadenectomy Elective lymphadenectomy for intermediate thickness melanoma yields pathologically positive nodes in 8-19% only 80% of patients are subjected to the morbidity of lymphadenectomy needlessly

19 Sentinel Node Biopsy Definition: A node that has independent and direct lymphatic drainage from a particular area of skin Objective: To identify patients with microscopic disease in clinically negative nodes without the morbidity of a formal regional lymphadenectomy

20 Sentinel node biopsy Prognostic 100% of the time Regional disease control improvement 20% Survival benefit 5%

21 Sentinel node biopsy The primary role of sentinel node biopsy may be to select patients who are most likely to benefit from not only regional lymphadenectomy but also systemic adjuvant therapy

22 The New England Journal of Medicine June 30, 2011 Ipilimumab plus Dacarbazine for Previously Untreated Metastatic Melanoma Caroline Robert, M.D., Ph.D., Luc Thomas, M.D., Ph.D., Igor Bondarenko, M.D., Ph.D., Steven O Day, M.D., Jeffrey Weber M.D., Ph.D., Claus Garbe, M.D., Celeste Lebbe, M.D., Ph.D., Jean-François Baurain, M.D., Ph.D., Alessandro Testori, M.D., Jean-Jacques Grob, M.D., Neville Davidson, M.D., Jon Richards, M.D., Ph.D., Michele Maio, M.D., Ph.D., Axel Hauschild, M.D., Wilson H. Miller, Jr., M.D., Ph.D., Pere Gascon, M.D., Ph.D., Michal Lotem, M.D., Kaan Harmankaya, M.D., Ramy Ibrahim, M.D., Stephen Francis, M.Sc., Tai-Tsang Chen, Ph.D., Rachel Humphrey, M.D., Axel Hoos, M.D., Ph.D., and Jedd D. Wolchok, M.D., Ph.D.

23 Immunologic drugs Check point inhibitors PD1 inhibitors MAP Kinase inhibitors BRAF MEK The holy grail -? RAS inhibitors???

24 Basal Cell Cancer Options Excision and flap/graft LA majority Radiation diffuse bcc Aldara patient preference Mohs recurrent cases (rare) and sclerosing subtype, not for any particular anatomic site

25 Thyroid Nodule

26 Learning Objectives Understand the epidemiology of thyroid nodules Understand the appropriate work up of a thyroid nodule Appropriately select patients for surgery

27 Solitary Thyroid Nodule TSH US FNA

28 Epidemiology Prevalence of thyroid nodule Physical exam 8% Ultrasound >40% Autopsy 40-60% 14% of thyroid nodules will be malignant

29 Epidemiology Childhood/ Adolescent Irradiation 33% will develop a thyroid nodule 33% of these will be malignant Irradiation for acne/thymic enlargement Residence in Eastern Europe After April 26, 1986 Occupational exposure to RT (?)

30 Thyroid nodule Benign (85%) Follicular adenoma Dominant nodule in Multinodular Goitre Colloid Nodule/Cyst Thyroiditis Malignant (15%) Papillary Follicular Other

31 Evaluation Objective is to operate on patients with cancer and to minimize the number of operations done on patients with benign disease

32 Evaluation Over the last 40 years we have converted from a policy of liberal removal of thyroid glands to a selective approach based on FNAB This approach will invariably miss some cancers

33 Evaluation History Physical TSH U/S FNAB

34 History Extremes of Age < 20 yrs of age >60 yrs of age Gender Male malignant in 20-30% Female malignant in 10%

35 History Low dose irradiation 30% risk of malignancy in a thyroid nodule Family history of thyroid cancer Rapidly enlarging nodule

36 Physical Size Nodules > 4cm have a high incidence of malignancy Adenopathy Vocal cord paralysis Fixation

37 TSH Laboratory testing

38 Ultrasound < 1cm nodules can be followed due to very low risk of malignancy US features very important in risk stratification of thyroid nodules But these features are rarely reported!!!!

39 FNA based on US findings Purely cystic no FNA Very low risk features- FNA if >2cm Low risk features FNA if > 1.5 cm Int/High risk FNA if > 1cm If High risk US and benign FNA still needs surgery

40 FNAB Best single test for evaluation of the thyroid nodule But not perfect! False +ve 5% False ve 14%

41 Who does a FNA? Radiology dept US guided I do US guided Dr. Moldoveanu If he replaces his broken US machine Any ENT or Endocrinologist if palpable Pathology dept ( Dr. Salina) if palpable

42 Bethesda Reporting System Benign Non Diagnostic FLUS (follicular lesion of undetermined significance) Follicular neoplasm Suspicious for malignancy Malignant

43 Benign cytology If high risk US features or size> 4.5 still need to consider surgery as risk of cancer can be 15% or greater US features low/int risk repeat US in 1 yr, repeat fna if >50% volume increase US very low risk no further fu

44 Non diagnostic 10-20% risk cancer Repeat FNA If two FNA non diagnostic - surgery

45 FNAB What constitutes a benign cytologic diagnosis? Cellularity Colloid Interpretation Few follicular cells Few follicular, numerous histiocytes Numerous Follicular cells Abundant Variable Variable Benign colloid nodule Benign cystic goitre Follicular neoplasm

46 FNAB Potential overlap in cytologic features between benign colloid nodule, FLUS and follicular neoplasm

47 FLUS 16% risk cancer Repeat FNA in 3-6 months Directly to surgery if high risk US features? Molecular testing

48 Follicular neoplasm 20% risk of cancer? Molecular testing Diagnostic hemithyroidectomy

49 Suspicious for Malignancy 70-80% risk of cancer Diagnostic hemithyroidectomy

50 Papillary thyroid cancer Lateral neck US Hemithryoidectomy acceptable if low risk < 4 cm Total thyroidectomy for larger or high risk cancers RAIU based on pathology

51 Solitary Thyroid Nodule The Gold Standard is Hemithyroidectomy

52 Indications for Thyroidectomy Malignancy or the risk of Malignancy Compression Failure of medical management of hyperthyroidism

53 Solitary Thyroid Nodule Solitary thyroid nodules are common and the majority are benign FNA combined with clinical features is a safe method of selecting patients for surgery Over reliance on FNA alone can lead to inappropriate management decisions