HJNO May/Jun 2021

HEALTHCARE JOURNAL OF NEW ORLEANS I  MAY / JUN 2021 57 Sukesh Manthri, MD Medical Oncologist Terrebonne General Mary Bird Perkins Cancer Center • Presence of atypical melanocytic nevi. The “ugly duckling” sign, the ABCDE (asymmetry, border irregularity, color var- iegation, diameter >6 mm and evolution) rule of melanoma and the Glasgow revised seven-point checklist can help identify melanoma. Imaging technologies, including dermos- copy, total body photography, reflectance confocal microscopy (RCM), optical co- herence tomography, electrical impedance spectroscopy and multispectral imaging, may improve the early recognition of mela- noma. Among them, dermoscopy is the most widely used and studied diagnostic tool, with total body or lesion-directed photography assisting in clinical surveillance. A skin biopsy is the first step to establish the histopathologic diagnosis of melano- ma. Evaluation of the entire tumor from an excisional biopsy, rather than a wedge or punch biopsy, is recommended to ensure measurement of the thickest part of the le- sion; a shave biopsy can compromise this evaluation and is therefore discouraged. STAGING The eighth edition of the American Joint Committee on Cancer (AJCC) tumor, node, metastasis (TNM) staging system is used for staging. Tumor thickness measured in mm (Breslow thickness) is a continuous variable that is associated with risk. Ulceration is an important prognostic factor and is defined as the absence of an intact epithelium over the melanoma. Mitotic rate is a significant prognostic factor within all tumor thickness categories, and it should be assessed and recorded in all primary melanomas.. TREATMENT Surgical management of primary cuta- neous melanoma: The recommended width of resectionmargin of normal tissue around the lesion has progressively decreased as a result of multiple large clinical trials. For melanomas ≤1 mm thick (T1), we use a 1-cm margin of normal tissue. For melanomas >1 to 2 mm thick (T2), we use a 2-cmmargin of normal tissue. For >2 mm thick melanoma, clinical trials have not demonstrated any benefit for excision margins >2 cm. Lym- phatic mapping with sentinel lymph node biopsy (SLNB) is the standard approach for the management of patients withmelanoma in whom there is a significant risk of region- al node metastasis. Systemic treatment options for ad- vanced cutaneous melanoma: High-dose interleukin-2 (IL-2) was the first treatment to modify the natural history of a small fraction of patients with metastatic mela- noma andmay have resulted in cure in them. However, its severe toxicity limited its ap- plication. More contemporary research led to the development of immunotherapy us- ing checkpoint inhibitors (the programmed cell death 1 [PD-1] inhibitors [e.g., pembroli- zumab, nivolumab] and cytotoxic T lympho- cyte-associated protein 4 [CTLA-4] inhibi- tors [e.g., ipilimumab]) and targeted therapy (BRAF plus MEK inhibitors). High-risk, node-negative (stage IIB or IIC) disease: Patients without lymph node involvement but with high-risk features in their primary tumor are at increased risk for recurrence and disease dissemination. Adjuvant therapy with checkpoint inhibitors or targeted agents has not been evaluated in this patient population, as patients were excluded from the phase III clinical trials. Patients should be offered enrollment in clinical trials when available. Stage III disease: For most patients with stage III melanoma, adjuvant immuno- therapy with one year of either nivolumab or pembrolizumab, is generally indicated. For patients whose tumor contains a BRAF V600 mutation, dabrafenib and trametinib could be an alternative. Stage IV disease: Checkpoint inhibition with a pembrolizumab or nivolumab in combination with ipilimumab has better ef- ficacy (response rates, progression-free sur- vival) than single-agent anti-PD-1 therapy in patients with advanced melanoma who are candidates for systemic therapy. For pa- tients whose tumor contains a BRAF V600 mutation, BRAF/MEK inhibitors could be an alternative. Simultaneous inhibition of BRAF and MEK improves response rates and sur- vival compared with BRAF inhibition alone and has replaced the use of single-agent BRAF inhibitors. Options include dabrafenib plus trametinib, vemurafenib plus cobi- metinib, and encorafenib plus binimetinib. For subsequent line of therapy, whenever possible, the tumor should be assayed for the presence of a driver mutation. Melanoma has become a worldwide pub- lic health concern. Ultraviolet (UV) radia- tion has been implicated as a risk factor for melanoma. Shade structures, sun-protective clothing, sunscreen and other measures can provide sun protection. Primary care clini- cians who identify a skin lesion that is not clearly benign or a change in a long-stand- ing mole or a new, persistent skin lesion, es- pecially if growing and pigmented, should have a relatively low threshold for referral to a dermatologist for dermoscopic exami- nation and evaluation of whether biopsy is indicated. Early diagnosis is crucial to improve patient outcome and save lives. n Sukesh Manthri, MD, is a medical oncologist at Terrebonne General Mary Bird Perkins Cancer Center, in Houma,Louisiana.He received amedical degree from the Prathima Institute of Medical Sciences in India. He completed a clinical research fellowship in Cleveland Clinic Florida,followed by an internal medicine residency atSouthern IllinoisUniversity inSpringfield.Subsequently, he completed a hospice and palliativemedicine fellowship at Saint Louis University, St. Louis, Missouri. Manthri, was a medical oncology fellow at East Tennessee State University,Johnson City.In 2020,Manthri received the Dr. Thomas G.RonaldAward for Excellence in the Care of the Cancer Patient.He is board certified in oncology, internal medicine, hospice and palliative medicine.