Optimal Management of Locally Advanced Melanoma

Jeffrey S. Weber, MD, PhD: Hello, and welcome to this OncLive® Peer Exchange® titled “Advances in the Treatment of Malignant Melanoma.” I’m Dr Jeffrey Weber. I’m from the Perlmutter Cancer Center at NYU Langone Health in New York, New York. Joining me today in this virtual discussion are my colleagues Dr Sunandana Chandra, who’s from the Robert H. Lurie Comprehensive Cancer Center at Northwestern University in Chicago, Illinois; Dr Adil Daud, who’s from the UCSF Helen Diller Family Comprehensive Cancer Center in San Francisco, California; Dr Jason Luke, who’s from the UPMC Hillman Cancer Center in Pittsburgh, Pennsylvania; and Dr Ryan Sullivan, who’s from Massachusetts General Hospital Cancer Center in Boston, Massachusetts. Welcome.

Today we’re going to review the latest data on melanoma released from the 2020 ASCO [American Society of Clinical Oncology] Annual Meeting. Let’s get started on our first topic.

The first topic talks about perioperative approaches to melanoma. A question that we medical oncologists deal with is: What’s the optimal approach to the multidisciplinary management of locally advanced melanoma? Ryan, tell me, how do folks at your institution handle the multidisciplinary management of the disease?

Ryan J. Sullivan, MD: Thanks, Jeff, for the introduction. It’s great to be here with such wonderful colleagues. One of the key parts of managing patients with early-stage high-risk melanoma is the multidisciplinary approach. I think there are 3 critical team members in terms of those who are patient facing: the dermatologist, the surgical oncologist, and the medical oncologist. Then there are a number of other critical people as well, including the dermatopathologists, radiologists, and of course all the support teams that help our patients.

What we tend to do at Mass General is a 2-step approach. The first step is the dermatology, cervical oncology clinic to meet patients who are maybe diagnosed with melanoma. Then we have a review at a multidisciplinary tumor board, and then typically we have a surgical oncology, medical oncology appointment that’s jointly visited. It’s a little spin on the traditional multidisciplinary clinic, where all the patient-facing doctors are seeing patients, but that’s typically how we do it.

Then we discuss the great majority of our cases, certainly any case where there’s a question of what’s the best management, and move forward. I’ll also mention that in the time of this COVID-19 [coronavirus disease 2019] crisis, we’ve found that these have been immensely helpful, because when we’re maybe making a slight change to what would have been the standard of care in the setting where we have open ORs [odds ratios], if there are limitations to that, it’s allowed us to apply novel approaches that have been certainly supported in literature to move forward with something that may not be the standard of care by NCCN [National Comprehensive Cancer Network] Guidelines.

Jeffrey S. Weber, MD, PhD: In your discussions with your surgical colleagues, how have those MSLT-II data—which frankly are now a couple of years old—they changed the extent and the role of the completion lymphadenectomy at your institution?

Ryan J. Sullivan, MD: For a few years before that, we were often discussing—for a patient who had a positive sentinel lymph node—whether the value of completing the lymph node dissection was appropriate for individual patients. A few years before the MSLT-II data came out, there were data from a randomized trial in Germany, which randomized patients with a positive sentinel lymph node to either completion lymph node dissection or monitoring with serial ultrasounds and exams, which found that there was no significant overall survival difference or distant metastasis presurvival among patients randomized to observation versus surgical complete lymph node dissection. What was important about that, though, is that there was a lot of trouble with that study in terms of powering. From a statistical standpoint, it did prove the principle that there’s probably some patients who we don’t necessarily need to do the completion lymph node dissection.

A year or 2 later, when the data came out almost overnight, it was data that was just directly published in the New England Journal of Medicine that had never been presented before. I remember the week before in tumor board, we were talking about doing completion of lymph node dissections, and the week after, we were talking about never doing another one. There are some scenarios where a completion lymph node dissection may be considered. Certainly, if there’s a palpable node that wasn’t part of the MSLT-II, those patients deserve a complete lymph node dissection, but in patients with positive sentinel nodes, it is the rare exception when we, in concert with our surgeons, recommend a completion lymph node—

Jeffrey S. Weber, MD, PhD: Let’s ask some of our other colleagues. I assume they have the same philosophy. How do you folks monitor the lymph node basins when you haven’t done a completion lymphadenectomy? Adil, what is done at UCSF?

Adil Daud, MD: We use ultrasounds to monitor the lymph node basin. As Ryan mentioned, when that DeCOG-SLT study came out—and that was, I want to say, ASCO 2015—we essentially stopped doing completion lymph node dissections. I’ve always thought it’s a staging, but sentinel lymph nodes are a staging tool, not a disease-control tool. I’ve never really thought that any of these studies would show a benefit, unless you’d have to think that you’re doing disease control from completion lymph node dissection. There’s been really no evidence from the previous WHO [World Health Organization] trials a long time ago, which maybe many of you don’t remember, but it was 20 years ago or so. To me, the whole sentinel lymph node biopsy, completion dissection, is really more of a diagnostic issue. We basically monitor people’s lymph node basins every 6 months with ultrasounds if you are not doing scans on those patients.

Transcript Edited for Clarity