Controversies and Questions in the Surgical Treatment of Melanoma

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Controversies and Questions in the Surgical Treatment of Melanoma Giorgos C. Karakousis, M.D. Assistant Professor of Surgery Division of Endocrine and Oncologic Surgery University of Pennsylvania School of Medicine

Financial Disclosures Consultant AMGEN, Castle Biosciences No relevant financial disclosures for this presentation

Clinical Questions/Controversies Three Clinical questions: 1. Who should get a SLN biopsy with thin ( 1.00 mm) melanoma? Are there low risk groups among patients with intermediate depth melanoma? 2. What are outcomes of patients who have a positive SLN biopsy with thin melanoma? How do they compare to those who develop clinical nodal disease? 3. Should patients with a positive SLN go on to get a completion lymph node dissection?

Reasons for SLN biopsy Prognostication/Staging Therapeutic value? Regional control of disease http://www.qualityoflife.org/memorialcms/images/cancer/

Morbidity of SLN biopsy Lymphedema rates ~5% Infection <5% Hematoma < 5% Seroma 5-10% Parasthesias 5-10% Anaphylaxis from dye injection <<1%

Clinical case #1 48 M with a 0.71 mm thick melanoma on the back, Clark level IV, 1 mitoses/mm2 (non-ulcerated, no LVI, no regression) http://cdn.lifeinthefastlane.com/wpcontent/uploads/2016/05/clinical-cases-litfl-logo.jpg

Predictors of SLN positivity in patients with Thin Melanoma Thin (T1) melanomas ( 1.00 mm) account for approximately 60-70% melanomas SLN positivity in this group is < 5% Current NCCN guidelines recommend discussing and considering SLN biopsy in T1a melanomas 0.76 mm and offering SLN biopsy in T1b melanomas 0.76 mm Little consensus as to which factors should drive decision for SLN biopsy in T1 lesions <0.76 mm

ASCO/SSO Guidelines for SLN biopsy Wong et al. JCO 2012; 30 (23): 2912-2918

NCCN guidelines for SLN biopsy Version 3.2016 Stage IA,B ( 0.75 mm any features*) WE alone Stage IA (0.76-1.00 mm) WE, consider SLN Stage IB (0.76-1.00 mm)/ II WE; discuss and offer SLN https://www.nccn.org/professionals/physician_gls/pdf/melanoma.pdf

Predictors of SLN positivity in patients with Thin Melanoma Bartlett, Karakousis et al Ann Surg Onc 2014

Predictors of SLN positivity in patients with Thin Melanoma Bartlett, Karakousis et al Ann Surg Onc 2014

Predictors of SLN positivity in patients with Thin Melanoma NCDB database T1 melanomas 0.5mm who had nodal evaluation 8,772 Thickness, ulceration, mitoses, Clark level, LVI, age ASC abstract submission 2017

Predictors of SLN positivity in patients with Thin Melanoma T Stage T1a T1b Age Total patients <0.76mm Positive Nodes, n (%) NCCN Guidelines Total patients 0.76mm Positive Nodes, n (%) NCCN Guidelines <40y 218 2 (0.9) NR 217 15 (6.9) Consider 40-65y 703 14 (2.0) NR 761 32 (4.2) Consider 65y 415 11 (2.7) NR 463 5 (1.1) Consider <40y 324 18 (5.6) NR 464 33 (7.1) Offer 40-65y 1091 33 (3.0) NR 1679 108 (6.4) Offer 65y 500 10 (2.0) NR 956 37 (3.9) Offer ASC abstract submission 2017

Low Risks groups for SLN positivity in Patients with Intermediate Depth Melanoma

Predictors of SLN positivity-intermediate Thickness Melanoma Bartlett, Karakousis et al ASO 2015

Predictors of SLN positivity: Intermediate-Thickness Melanoma Bartlett, Karakousis et al ASO 2015

Outcomes of Patients with Thin Melanoma after SLN biopsy

Outcomes of Patients undergoing SLN biopsy Final trial report MSLT-1 Among patients with nodal metastases, those who underwent SLN biopsy with immediate lymphadenectomy demonstrated improved survival in intermediate thickness group but not thick group. Morton et al NEJM 2014

Melanoma Databases Outcomes of Thin Melanoma Patients undergoing SLN biopsy Penn-JWCI study N=586 CNR (Clinical Nodal Recurrence) N=466 SLN+ pts N=120 Univariable Analysis Multivariable Analysis* Characteristic HR 95% CI p- value HR 95% CI p-value Sex Female Ref. -- -- -- -- -- Male 1.06 (0.83-0.651 -- -- -- 1.35) Age 50 years Ref. -- -- -- -- -- > 50 years 1.35 (1.06-0.016 1.42 (1.11-0.005 1.73) 1.81) Primary Extremity Ref. -- -- Ref. -- -- Site Axial 1.40 (1.08-0.012 1.42 (1.09-0.009 1.81) 1.85) Breslow 0.75 Ref. -- -- -- -- -- (mm) >0.75 1.24 (0.98-0.077 -- -- -- 1.57) Clark I-III Ref. -- -- -- -- -- Level IV-V 1.08 (0.80-0.62 -- -- -- 1.47) Unknown 0.78 (0.46-0.35 -- -- -- 1.32) Ulceration Absent Ref. -- -- Ref. -- -- Present 1.79 (1.15-0.011 1.92 (1.22-0.005 2.80) 3.01) Unknown 1.89 (1.46- <0.00 1.64 (1.27- <0.001 2.44) 1 2.12) Nodal SLN Ref. -- -- Ref. -- -- Evaluation CNR 3.42 (1.91-6.11) <0.00 1 3.29 (1.83-5.93) <0.001 Karakousis, Faries et al Ann Surg Onc 2016

Outcomes of Thin Melanoma Patients undergoing SLN biopsy SLN + Months Clinical Nodal Recurrence P<0.0001 Survival Probability SLN + Penn Penn JWCI Clinical Nodal Recurrence JWCI }SLN + }CNR P<0.00 01 Months

SLN biopsy in Patients with Thin Melanoma NCDB database T1 melanomas 0.76 mm 20,293 patients 13,944 underwent nodal evaluation (NE) Nodal positivity rate 3.9% NE evaluated NE not evaluated 89.7% (88.7-90.6)* 84.8% (83.7-85.8)* *5y OS (p<0.001) SSO abstract submission 2017

Regional Control with Lower Morbidity MSLT-1 If there is not a therapeutic role to SLN biopsy, is there a benefit with respect to earlier regional control of disease? Faries et al. Ann Surg Onc 2010; 17: 3324-3329

Regional Control with Less Morbidity No significant difference in acute morbidity between immediate and delayed lymphadenectomy group Mean Hospital stay longer in the delayed lymphadenectomy group (9.9 days) versus immediate group (8.3 days), although this could probably largely be accounted for by increased number of deep groin dissections Lymphedema rates higher in delayed versus early lymphadenectomy group Faries et al. Ann Surg Onc 2010; 17: 3324-3329

Clinical case #2 42 F with 2.3 mm thick non-ulcerated left leg melanoma with 1/2 + SLNs (0.4 mm micrometastasis intraparenchymal) Should patients with a positive SLN go on to get a completion lymph node dissection?

Completion lymphadenectomy or not for +SLN Incidence of finding additional non-sentinel nodes on completion lymphadenectomy for a + SLN is approximately 15-20% Various factors may help to predict which patients are at risk for harboring additional metastatic disease in the non-sentinel nodes Disease in the non-sentinel nodes may portend a worse prognosis Completion lymphadenectomy has been the standard approach for patients with + SLN, but randomized trial is currently underway to address the impact of this approach on melanoma-specific survival

Predictors of non-sentinel LN positivity Van der Ploeg et al. JCO 2011; 29 (16): 2206-14

Predictors of non-sentinel LN positivity 2 nodes + 104 mo P<0.001 66 mo p=0.04 36 mo 34 mo Ariyan et al. Ann Surg Onc 2009; 16: 186-190

DECOG study Leiter et al. Lancet Oncology 2016; 17 (6): 757-67

DECOG study Distant metastasis free survival Overall survival Leiter et al. Lancet Oncology 2016; 17 (6): 757-67

MSLT2 Study MSLT2 (N=1,939 proposed randomized pts with +SLN) Completion lymphadenectomy Observation with serial U/S Currently, completed accrual

Conclusions SLN biopsy is routinely offered to patients with T2 or greater melanomas ( 1 mm) and in patients with T1b lesions 0.76 mm SLN biopsy scan be selectively considered in other T1 lesions (+ deep margin, LVI, Clark level IV/V, high mitotic count) Primary value of SLN biopsy is prognostic/staging and therefore risks of procedure must be weighed against potential benefits. There may be therapeutic value, and increasingly so as newer adjuvant regimens are developed that can be used earlier in stage III disease. Completion lymphadenectomy remains the standard approach for patients with + SLN pending the results of the MSLT2 trial.

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