Invasive Melanoma Management

At the American Society for Dermatologic Surgery (ASDS) Annual Meeting, Kimberly Ken, MD, discussed how dermatologists can effectively manage advanced stages of melanoma.¹ Ken pointed out that it’s crucial to keep an eye on invasive melanoma, as there are predicted to be approximately 100,000 new cases of invasive melanoma in the United States in 2022, and the numbers will continue to rise.

Ken’s presentation focused on 3 main topics: sentinel lymph node biopsy (SLNB), imaging, and systemic therapy. Beginning with SLNBs, the biopsies are meant to accurately stage patients through pathologic assessments of the regional nodal basins and provide prognostic information. In clinical stage I or II melanomas, SLNBs are one of the most important prognostic factors for patients. Finally, SLNBs can impact future therapies by encouraging dermatologists to consider if they will offer adjuvant therapy, ultrasound monitoring of the nodal basin, or follow-up with surveillance imaging.

The National Comprehensive Cancer Network (NCCN) makes recommendations on when to perform an SLNB based on the likelihood that a patient will have a positive SLNB. For stage T1A melanomas without adverse features, the probability of a positive SLNB is less than 5%, so an SLNB is not recommended by the NCCN. There is a subset of T1A melanomas that have adverse features. These patients have tumors with a mitotic index greater than 2, especially in younger patients, and it would be recommended to consider an SLNB.

Moving on to imaging, Ken then discusses baseline imaging. In stages 0 to II, baseline imaging is not recommended. In stage 3A for patients with a positive SLNB, it’s important to consider cross-sectional imaging such as CT chest, abdomen, pelvis, and even the neck. In stage 3B-D, cross-sectional imaging with a brain MRI would be best. And finally, in stage 4, cross-sectional imaging with brain imaging should be done at baseline. If a patient has had brain metastasis, a brain MRI should be performed more frequently than someone who hasn't.

“So I know you're probably thinking, ‘we don't often do these,’ but we really do them in coordination with our medical oncology colleagues and our surgical oncologists. When we're having discussions with our patients, when we're seeing them back from their alternating visits with us and other specialties, we really want to be involved in their care and know what's happening and be able to advocate for them,” said Ken.

At the end of her discussion, Ken discussed the role of adjuvant therapy. The goal of adjuvant therapy is to improve the survival of patients and reduce the risk of recurrence. When discussing systemic therapy, Ken is mainly talking about immunotherapies like PD-1 inhibitors and targeted therapies. The treatment for melanoma has changed drastically since 2011. Previous chemotherapy agents didn't have durable responses or positive survival benefits, and not to mention the adverse effects.

When discussing adjuvant therapy with immunotherapy or targeted therapies, the risk of recurrence and adverse effects must be addressed. Patients can develop life-threatening myocarditis, pneumonitis, or hypothyroidism. While adjuvant therapy does not come without risks, the overall goal is to improve the survival rate.

“With advanced unresectable melanoma, immunotherapy was first approved by the US Food and Drug Administration in 2014. For stage III melanoma, nivolumab was approved in 2017, and pembrolizumab was approved in 2019. Most recently, pembrolizumab is now approved for stage 2B or C melanoma. Last month, the CheckMate –76K (NCT04099251) trials showed that nivolumab did meet its interim analysis with improved recurrence survival in patients treated with nivolumab, so I think we’ll see that approval coming hopefully in the next year or 2,” said Ken.

Ken believes that dermatologists will see melanoma patients in their clinics more and more, and she stressed how important it is to stay up to date on methods and to participate in tumor boards.

Reference:

1. Ken K. Melanoma Update. Presented at: 2022 American Society for Dermatologic Surgery Annual Meeting, October 7-10, Denver Colorado.