Managing uncertainty in Spitz Nevi melanoma

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Published: 22 Nov 2018
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Prof Vernon Sondak - H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida

Prof Vernon Sondak speaks with ecancer at the EADO 2018 congress in Barcelona about managing the uncertainty of Spitz Nevi melanoma.

Prof Sondak explains that there is a small number of atypical spitz tumours where it is difficult to determine whether it is truly benign or if it is truly cancerous, leading to confusion and uncertainty for patients and doctors.

He details that there are ways to manage the uncertainty and that, if it comes to it, they can treat the worst case scenario, which isn't always as bad as feared.

ecancer's filming has been kindly supported by Amgen through the ecancer Global Foundation. ecancer is editorially independent and there is no influence over content.

We are seeing a very significant increase in the number of young patients – children, adolescents, young adults – who are getting skin lesions biopsied. There is more awareness of melanoma and other things like that in children; there are more paediatric trained dermatologists who are willing to do biopsies in children and Spitz nevi and their closely related cousins are very common in this age-group, children, young adults and adolescents. The problem is they’re very, very difficult sometimes for the pathologist to discern are they benign, are they malignant, are they somewhere in between. Even our team with pathologists with a very, very high degree of expertise in this area recognise that there are some of these moles that, with the best available technology, we cannot predict how they are going to behave. Some are totally benign and are just like any other mole; some are clearly a melanoma that’s just masquerading as looking like a benign Spitz nevus; melanoma loves to hide out and pretend it’s something else and one of the things it can pretend to be is the Spitz nevus and we call that a Spitzoid melanoma. That’s pretty much a tumour that needs to be treated like any other melanoma in a person of the same age. But in the middle is a small but persistently problematic group of atypical tumours, we like to call them atypical Spitz tumours, there are a number of different names that have been given, where the pathologist sees something about them that isn’t right. We can’t say this is totally benign and yet can’t say it’s unequivocally cancerous.
These are a huge challenge; we don’t know whether they are increasing in number or they’re just coming to our attention more because we’re doing more biopsies. But either way we’re facing this problem a lot and it’s tough for the doctors but it’s tough for the family and the patient as well when the doctor doesn’t seem to know exactly what’s going on or when they send it out for several opinions and prominent, famous pathologists disagree and one says, ‘Oh, it’s fine,’ and the other says, ‘Oh, I’m very worried about it.’ Other times there’s all sorts of jargon in the report and no-one’s really sure is that good or bad.

One of the things our group and our pathologist in particular has worked on a lot is how do we communicate between the pathologist and the surgeon and between the surgeon and the family and the patient what we’re seeing so that if the pathologist says, ‘Yeah, there’s a few little atypical areas but nothing that makes me worried about this having a chance to be cancerous and spread,’ that’s very different than the other extreme where the pathologist says, ‘This is a wildly atypical tumour, there are a few checkboxes that I can’t check off to call it melanoma and just send it out the door but I’m very worried about this.’ Then there are some in the middle where the pathologist isn’t sure at all – there are just a few things that are very worrisome and what do they mean. We want to know the difference between all three of those scenarios and we may well manage all three of them a little bit differently.

So we work very closely with the pathologist, try to enhance that communication. We also spend a lot of time communicating with the family that it isn’t an absolute black and white diagnosis, that there is uncertainty but that we have ways to handle that uncertainty, that we can treat the worst case scenario and even the worst case scenario isn’t always that bad. Even if we know it’s melanoma, many melanomas in children we can cure very readily and they have a good outcome. So we want to remind people that we’re going to take care of the worst case scenario but the worst case scenario isn’t always that bad. On the other hand, what we don’t want is the opposite where we tell the person and their family that it’s nothing to worry about and it comes back to haunt them later on. We recognise that there is uncertainty, we incorporate it into our discussions and we try to manage that uncertainty.

The other aspect that I talked about is we do use the sentinel node biopsy as one of the ways we help discriminate in these very atypical lesions, the ones that at least the pathologist cannot say for sure, ‘I think this is totally benign.’ Sometimes a sentinel node biopsy can help us, sometimes molecular testing can help us and that’s something we also rely on very heavily. But in the end there are times we have to manage the uncertainty and follow the patient very, very closely. As long as everyone is aware of what we’re dealing with, again as long as we avoid that trap of saying, ‘Don’t worry about it, it’s nothing,’ and it turns out it wasn’t, I would rather be a little bit more cautious and a little bit more err on the side of careful surveillance in these situations.

How important is the role of the conference to communicate these different strategies?

Clearly conferences like this are so important in tackling these kinds of cutting edge issues. Sometimes when you practise in a place like I do, a very multidisciplinary centre that is focussed very heavily on unusual cases, and in my case and in my team’s case particularly in the management of these atypical lesions in children, we forget that most of the time they are being seen by someone who may have never encountered this problem because it is still a pretty rare situation. When we come to meetings like this it’s really eye-opening to me, I get to meet people from all over the European continent and recognise how different the healthcare systems are, how different the access to specialised care is. So just getting some of these concepts out there is extremely important and helps refine the message that we want to give but also helps educate and helps us reach people all over the globe. One of the nice things, one of the benefits I’ve had of being involved with this particular organisation, EADO, and the International Melanoma Centres Group for years is that we do meet people from all over the world, we continue to communicate. It’s not unusual for me to get an email from somebody in Europe or Australia or Canada saying, ‘Hey, I’ve got one of these children and we’ve got an unusual situation, what should we do?’ And sometimes we can provide some assistance and make sure that they cover all the bases.