What is the role of surgery in melanoma treatment?
Dr Alessandro Testori - Istituto Europeo di Oncologia, Milan, Italy
Today I’m going to talk of a quite innovative concept which is the possibility to re-explore surgical aspects after you’ve done some other treatments to cure the disease, in this case melanoma which is characterised by specific situations which before the development of new treatments that now we have available we could not think about offering after the treatments the surgical opportunity to these patients. Now that there are treatments which are effective you can obtain a situation where maybe surgeons like me can come back to the bed of the patient and propose further treatment from this point of view.
What treatments have you been working with?
My presentation is divided into the different stages of the disease. So we start with clinical situations on the primary melanoma or on the large primary skin cancers where the only alternative could be major surgery which goes also to amputations if the primary disease is, for example, on a foot. I present two cases of patients with large primary tumours which, from the surgical point of view, could not be just resected - the resection would imply also the demolition of part of the body like the foot or the leg. My first part of the discussion is in fact dedicated to the possibility to do a treatment before, one is the limb perfusion which is a treatment that isolates the vascularisation of the limb and you create an extracorporeal circuit through which you isolate completely the bloodstream of the district that you want to treat, which is the limb. In this way you can introduce into the circuit a very high concentration of drugs, you raise the temperature of all the system, of the blood, and the combination of this high temperature and of the anti-tumoural drugs obtains a very important anti-tumoural effect and in fact the tumour shrinks. Then at the end after two, six, four months you can do a very limited operation to resect the residual of the disease if there is any residual disease.
The other approach I’m proposing is electrochemotherapy, again on large primary melanomas. Again, this is local regional treatment, very, very effective on specific situations and the cases that I have been treating with this approach on primary melanomas have given us always very good results in terms of conservation of the anatomical structures and of efficacy against the tumour. This is a very particular situation so far, nowadays it’s not so frequent to have large, huge primary lesions because people finally come a bit earlier than it was fifty years ago to get doctors’ advice, but sometimes it happens. When you find these situations the alternatives are either, as I said, a major surgical procedure or you have to invent something different and these approaches can offer us a conservative methodology of treating our patients.
The next step for the treatment of this disease is the situation where we have to treat patients with the so-called in-transit metastasis. These are tumoural lesions that develop along the lymphatic stream in between the primary disease and the local regional nodes. If you have this kind of progression of the disease your quality of life is deteriorated and your prognosis is certainly worsening. Here my presentation starts with the concept that we have probably more questions than answers to offer to solve this situation and this is because we don’t have so many studies to say what is better first. Is it better to start with the local regional approach like the ones that I was mentioning before for the primary disease or is it better to start with the systemic treatment. It’s a difficult answer because if you start with the new effective treatments and the disease is only limited to the skin then in case in the future of the life of the patient he would develop visceral metastases - brain, lung, liver metastases – what would you offer to this patient? On the contrary, we think that if you treat these patients with these systemic treatments which are the checkpoint inhibitors, which are the targeted therapies which are finally effective in melanoma, if we treat these patients with a limited amount of disease it’s probably better than if you treat these patients with larger and bulky tumours. So it’s something that we don’t know.
What is the solution? Well the solution is to discuss it with patients and with all the colleagues involved so you need to be a surgical oncologist, you need to be a medical oncologist, you need to put the radiologists and the pathologists into a room and discuss the various options that you can offer to the patient and then, in front of the patient, you have to show the different offers, the different treatment modalities that you can prepare and you can propose to him. Then the decision has to be taken in between the doctor and the patient himself because if you don’t have anything to say this is better than that and a lot of options are at the same level the only thing that you can do is to discuss it with the patient and then from his point of view you will try to modulate the better decision for him.
Then there is the situation where the patient presents with advanced disease, so it’s the so-called stage 4. Stage 4 which means the presence of metastasis to different parts of the body Here the surgical option has been always the only one before the era of the new drugs. This was the only option but the only option when it was feasible because the alternative when you had really several lesions everywhere in the body was to do chemotherapy with an efficacy of 5% of survival at five years, so very, very limited success. Now we can start to say that at least half of our patients may be able to survive; we have the evidence of the durability of efficacy of the new treatments. The point again comes when you have these situations of patients who have obtained regression, not a complete response but a regression, a partial regression of the tumour. Here again the surgical approach can be proposed. So you come back to the surgeon with a medical oncologist to discuss each single patient who may benefit from resection of the residual of the disease who may not have completely disappeared with these new treatments. It’s a very new situation because until five or six years ago we didn’t have any patients, I would say, who is alive with a limited amount of disease after the treatment. Either you had very few patients, anecdotal patients, with a complete response or you had patients progressing. But very, very difficult was to say that we could have patients who had a situation, an inoperable situation, at the beginning, they had a treatment and they reduced the tumour to the situation where the surgical indication could be proposed back. This is what is instead now happening. Of course we don’t have numbers because it’s something that we are seeing since a few years and statistically we don’t yet know if this surgical indication would really help in improving the survival of our patients or not. We’ll see, it takes time to get the numbers, to get the experience on this kind of situation but certainly we are discussing patients also from the surgical point of view after they have been treated from the medical point of view.
Any final thoughts?
The advice is always that melanoma patients and skin cancer patients should be treated in a multidisciplinary setting. It’s important that these patients are referred to an academic institution where you have dedicated doctors. Don’t treat patients in a naïve way. One of the slides I’m presenting is a slide coming from a plastic surgeon in a peripheral hospital in Italy. He showed us the slides where he made major resection on a limb of a patient but this was due to the presence of the so-called in-transit metastasis on the limb of this patient. He made the resections as large as this which is totally un-useful because you perfectly know that the next day that the skin graft has healed this poor person will develop other in-transit metastases just aside and you have destroyed half of the leg of a person which is totally absolute. So really think not as good as you are the best plastic surgeon in this case, but think about treating patients from a global oncological idea and not just because you are the best plastic surgeon do devastating surgery because you know how to repair it. Because from the oncological point of view you have done nothing good to this patient.