“This is a field that has changed dramatically in the last few years, and it’s hard to keep up with everything that’s going on,” he said, adding that he would discuss clinical trials as well as standard therapy with this patient.
Explore This IssueNovember 2016
Dr. Liu agreed, saying, “These are the exact kind of patients [in whom] we know prognosis is poor, but we may address that prognosis tremendously with a new agent.”
The NCCN guidelines recommend offering clinical trials for treating unresectable metastatic melanoma. “The take-home message I want you to remember,” Dr. Schmalbach said, “is that we have a lot of options with respect to metastatic melanoma, but there is never going to be one single magic bullet. That’s because there are multiple different genetic mutations that are associated with melanoma, as well as 30% of patients who don’t have a detectable mutation.”
Case 3: Merkel Cell Carcinoma on the Head
A 67-year-old male presented with a rapidly growing 3-cm, biopsy-proven Merkel cell carcinoma (MCC), staged as T2N0M0, on the top of the head.
Dr. Liu, who oversaw the case, said one of three sentinel lymph nodes was positive, so the patient was upstaged to a T2N1 cancer. He pointed out the deeper understanding of MCC that’s evolved over the years: It’s now known that the disease is “exquisitely radiosensitive and quite treatable with radiation. The question is how much surgery should we give in addition to the radiation for treatment.”
The NCCN guidelines offer up multiple options for how to approach these patients and, in this case, the panel was split on whether to perform a completion lymphadanectomy.
We have a lot of options with respect to metastatic melanoma, but there is never going to be one single magic bullet … because there are multiple different genetic mutations that are associated with melanoma. —Cecelia Schmalbach, MD, MSc
An audience member asked why a sentinel node biopsy is necessary if radiation would be performed anyway. “The reason for the sentinel node biopsy is that it focuses the field of radiation into where it’s positive,” Dr. Wang said. This study is helpful for midline lesions, which could drain to either side. Determining laterality can spare unnecessary radiation toxicity. “That would be my argument as to why sentinel node biopsy still has a role,” he added.
Dr. Bradford said that, at the University of Michigan, the recommendation would be to perform a parotid and neck dissection and then radiate according to the risk tumor burden and the number of positive nodes. But, she said, there is no hard data to go on, largely because Merkel cell carcinoma remains a fairly rare and unusual malignancy. She hopes cohort data, at least, becomes available to better guide physicians in how to treat these patients.