Jeffrey Liu, MD, associate professor of otolaryngology-head and neck surgery and director of the division of head and neck oncologic surgery at the Lewis Katz School of Medicine at Temple University and Fox Chase Cancer Center in Philadelphia, said he would recommend a 2-cm margin on this tumor, rather than a smaller margin, due to the biology of the disease. It has a high local recurrence rate and can actually be much more difficult to control than traditional melanomas, he said, adding that he would perform mapping biopsies in the office.
Explore This IssueNovember 2016
Steven J. Wang, MD, interim director of otolaryngology-head and neck surgery at the University of Arizona in Tucson, agreed with the larger, 2-cm margin for this case. “The key thing here is, on the scalp, I see no downside to favoring a larger margin,” he added.
Following surgery, the dermatopathologist’s report showed deep invasion—7 mm down to Clark’s level 5. While the surgery had achieved negative margins, Dr. Liu said that he would still recommend adjuvant radiation therapy to maximize the chance for locoregional control. “By every measurement, this is a high-risk cancer patient,” he added.
Dr. Bradford didn’t agree that this was a clear-cut case for adjuvant therapy. There’s no prospective data that adjuvant radiation therapy will offer a patient improved overall survival. “However, this is a worrisome lesion,” she added. “I think adjuvant radiation merits a discussion in multidisciplinary, tumor-board fashion. But you have attained clear margins, fairly significantly clear margins, so I personally am a little bit on the fence about radiation in this circumstance.”
Case 2: Third Diagnosis of Melanoma
A 65-year-old English professor with a history of a T2M0M0 right post-auricular melanoma had been treated in 2008 with wide local excision and sentinel node biopsy, which was negative. Two years later, he presented with melanoma in situ; again, it was resected with negative margins. In 2016, he presented with a melanomic lesion biopsied at an outside center and had a melanoma diagnosis for the third time. A repeat punch biopsy confirmed the lesion as melanoma in situ. The patient experienced no symptoms at all.
He was scheduled for a wide local excision, but on preoperative X-ray, a mass was found in his chest and found to be metastatic melanoma to the right lung. The panelists agreed that realistic options at this point included ipilimumab, PD-1 blockers, and combination therapy.
With this patient, Dr. Wang said he would lean a lot on his medical oncologist.