Melanoma incidence is on the rise, and treatment recommendations are evolving. What does the practicing surgeon need to know? In yesterday’s Panel Session “Modern Melanoma Management,” surgeons addressed current science on patient survival and recovery.
Carlo Contreras, MD, FACS, from The Ohio State University in Columbus, focused on primary treatment, including diagnosis and staging. He reasoned that shave biopsies are as good as punch biopsies, and risk calculators may help clarify the need for sentinel lymph node biopsies. He also commented on imprecision in current guidelines on the surgical margins necessary in excision of lesions that are 1–2 mm deep. Calling the range of 1–2 cm “like picking from a menu,” Dr. Contreras noted the forthcoming MelMarT-II randomized clinical trial (RCT) results may provide clarity.
Giao Q. Phan, MD, FACS, from UConn Health in Farmington, Connecticut, also cited several RCTs in her presentation, which asked, “When does a melanoma patient need more than surgery?”
Her data showed that the 5-year survival rates of patients with stage IIB and IIC melanoma are worse than those of patients with stage IIA disease. She posited that the reasons include under-staging, biological factors, and inadequate follow-up; she added that adjuvant therapy is a valid option for these patients.
Similarly, Dr. Phan showed current research establishing that adjuvant and neoadjuvant agents can benefit patients with higher-stage melanoma. She explained that prompt complete nodal dissection in patients with stage III disease did not offer improved outcomes over a practice of initial observation. Instead, a 2021 study established that patients with resected disease in stages IIIA, B, or C benefited from pembrolizumab administration.
Dr. Phan further highlighted that specific adjuvant agents can improve survival, as with patients with stage III or IV melanoma given nivolumab rather than ipilimumab. She noted that use of adjuvant therapy before rather than only after surgery increases progression-free survival, perhaps because in situ tumors act as autologous vaccines during immunotherapy, “teaching the T cells what is the bad guy.”
Despite positive results in several trials of adjuvants, Dr. Phan said, “After 5 years with even the best therapy, for approximately 50% of patients, these drugs will not work.”
A new line of therapy may help resolve this issue, she said. Tumor-infiltrating lymphocytes (TIL) occur naturally at tumor sites in small numbers; harvesting these, growing large quantities in a laboratory, and returning them to the site may aid patients with disease refractory to other care. While Dr. Phan presented evidence of benefit, she said, “We can only get to cure with more testing.”
Marybeth S. Hughes, MD, FACS, from Eastern Virginia Medical School in Norfolk, then took the podium to share clinical cases, calling this “the fun part of the lectures.”
She walked through several cases, at one point asking if sentinel lymph node biopsy was essential to an elderly man with melanoma in his forearm, acknowledging that many attendees shook their heads “no,” and then explaining why the patient did require biopsy due to relatively subtle factors in his case presentation.
Dr. Hughes’s final case aligned with Dr. Phan’s presentation. It showed a massive refractory metastatic melanoma on a patient’s head that resolved with conditioning chemotherapy and a TIL infusion that included interleukin-2. “It’s important that that’s now part of our armamentarium,” Dr. Hughes commented.
The Panel Session is available on demand to all Clinical Congress registrants.
