Melanoma Prevention, Detection, and Treatment - 5.17.18 - Dr. Eric Huang and Dr. Zubin Bamboat

Sun safety needs to start at an early age in order to reduce the risk for skin cancer. Learn from Summit Medical Group MD Anderson Cancer Center specialists about prevention and ways to reduce your risk, diagnosis and innovations in skin cancer treatments.

1. Melanoma Prevention, Detection, Treatment Eric Huang, MD - Dermatology Zubin Bamboat, MD, FACS – Surgical Oncology

2. The Partnership Summit Medical Group MD Anderson Cancer Center offers cancer patients in Northern New Jersey access to cancer treatments that are among the most advanced in the nation. Our experts adhere to the multi-disciplinary care, treatment innovations and standards of care of MD Anderson Cancer Center’s clinical leadership and provide a full range of cancer services, including medical oncology, surgery and radiation. We offer leading oncology services covering all aspects of patient care, from routine screenings, diagnostics, treatment and surgery to survivorship in Berkeley Heights, Morristown and Florham Park. New Radiation Oncology Department in Berkeley Heights Summit Medical Group MD Anderson Cancer Center in Florham Park.

3. Summit Medical Group MD Anderson Cancer Center Cancer services include : Breast Care Center Dermatology Genetics Gynecologic Oncology Hematology and Oncology Infusion Center Nutrition Palliative Care Plastic Surgery Radiation Oncology Surgical Oncology Thoracic Surgery

4. Melanoma Define Melanoma Magnitude of Problem Prevention Detection Diagnosis/Staging Treatment

5. What is Melanoma

6. What is Melanoma

7. Melanoma Survival Stage at Diagnosis Stage Distribution 5 yr Survival Localized (primary site) 84% 98.2% Regional spread(nodes) 9% 62.4% Distant spread organs 4% 15.1%

8. What is Melanoma

9. Melanoma Define Melanoma Magnitude of Problem Prevention Detection Diagnosis Treatment

10. Magnitude of Problem

11. Melanoma 120,000 detected each year 8,700 death per year

12. Magnitude of Problem Most early detectable cancers: colorectal, breast, cervical and prostate have demonstrated substantial declines over the past 3 decades melanoma mortality rates have continued to rise

13. Melanoma Define Melanoma Magnitude of Problem Prevention Detection Diagnosis/Staging Treatment

14. Melanoma Risk Factors Sun Exposure (Ultra Violet Radiation) Family history of Melanoma Dysplastic nevi More than 50 moles Age/Gender Skin type Occupation Socioeconomic Status

15. Energy

16. Sunshine Rays

17. Ultraviolet Light

18. Modifiable Risk Factors Sunshine/ Ultraviolet Radiation Tanning Salons Sunshine

19. Tanning Salon

20. Tanning Salons 40-50% of 16-17 year old girls 2.3 Millions adolescents yearly More tanning salons per city than Starbucks or McDonalds Increase risk of Melanoma by 75% Legislation was passed NJ April 1, 2013 Banning tanning under age 17

21. Natural Sunlight

22. Natural Sunlight 5 sunburns doubles your risk of melanoma Cumulative and intermittent sun exposure High altitudes increase exposure Reflection off sand and snow increase exposure

23. Minimize Sunlight Avoid Sun 10am-4 pm Slip Sun Protective Clothing Slap Sunscreen Slop

24. Seek Shade

25. Seek Shade

26. Sun Protective Clothing

27. Sunscreen

28. Sunscreen

29. 1-2 ounce 30 minutes prior exposure Reapplied every 2 hours SPF 30- 50 Sunscreen

30. Sunscreens Creams Sprays

31. Sun Protection Slip Slap Slop

32. Does modifying sun exposure work? Increases use of sun protection Decrease sunburns Decrease thickness of melanoma

33. Melanoma Define Melanoma Magnitude of Problem Prevention Detection Diagnosis/Staging Treatment

34. Detection Increase the detectors General Public Spot the Spot ABCDE’s High Risk Patient Improve the detectors Technology Dermoscopy Full Body Photography

35. Melanoma ABCDE’s

36. A symmetry

37. Benign Mole — Symmetrical

38. Melanoma Asymmetrical

39. Melanoma — Asymmetrical

40. B order

41. Benign Mole — Even Edges

42. Melanoma — Uneven Edges

43. Melanoma — Uneven Edges

44. C olor

45. Benign Mole — One Shade

46. Melanoma — Two or More Shades

47. Melanoma — Two or More Shades

48. D iameter

49. Benign Mole — 6mm or Smaller

50. Melanoma — Larger than 6mm

51. Melanoma — Larger than 6mm

52. E volving

53. Melanoma — a Mole that Changes

54. Thin Melanoma

55. Spot the Melanoma?

56. Screening High Risk Patients New or Changing Mole ABCDE’s History of Melanoma Family history Melanoma Tanning salon users Older men All new patients

57. Screening American Cancer Society Every 3 years between 20-40 years Every year over 40 year

58. Improving the Detectors Dermatologist are the best at finding melanoma

59. Dermoscopy

60. Dermoscopy

61. Full Body Photograph

62. Melanoma Define Melanoma Magnitude of Problem Prevention Detection Diagnosis/Staging Treatment

63. Biopsy

64. Excisional Biopsy

65. Skin Sample

66. Skin Tissue Processed

67. Dermatopathologist

68. Melanoma Define Melanoma Magnitude of Problem Prevention Detection Diagnosis/Staging Treatment

69. Dermatopathologist Essential Tumor thickness Ulceration Mitotic rate Margins Anatomic Level Microsatellitosiss Optional Angiolymphatic Invasion Histologic Subtype Neurotropism Regression T stage Tumor infiltrating lymphoctes and vertical growth phase

70. Stages of Melanoma: 1-4

71. Surgical considerations Surgery only Surgery + medication Immune and targeted therapies

72. Surgical Treatment NCCN – Recommended Surgical Margins for Melanoma Tumor Thickness Recommended Margins In situ 0.5 cm ≤ 1.0 mm 1.0 cm 1.01 – 2 mm 1-2 cm 2.01 – 4 mm 2.0 cm ˃ 4 mm 2.0 cm

73. Surgical Treatment: Wide excision margin

74. Skin Grafting

75. Flaps

76. Flaps

77. How do we deal with the lymph nodes?

78. Who needs a sentinel lymph node biopsy: Invasive melanoma >1mm Melanomas >0.75mm – 1mm “consider” ( esp if MR >1mm 2 or ulceration) Goal: Detection of subclinical microscopic metastatic disease – improved staging and enhanced survival Sentinel lymph Node Biopsy

79. Sentinel lymph Node Biopsy: Blue Dye

80. Injection of radiotracer around melanoma Sentinel lymph node Sentinel lymph Node Biopsy: Lymphoscintigraphy

81. MSLT-1 Trial 1 Highlights the prognostic importance of sentinel lymph node in melanoma Over 1200 patients studied (1.2mm – 3.5mm thick melanomas) 2 main groups: WLE vs WLE + sentinel node biopsy Outcomes measured: 1. Death from melanoma 2. DFS 1. Morton DL et. al 355:1307-1717, NEJM 2006

82. Q. What about patients who have melanoma in their sentinel lymph node? Until 2017: completion lymph node dissection was considered standard for all patients

83. MSLT-2 Trial 1 What is the value of CLND in patients with positive sentinel lymph node? Over 1900 patients studied with positive sentinel lymph nodes 2 main groups: Observation only vs. immediate CLND Outcomes measured: 1. Death from melanoma 2. DFS No difference in death from melanoma at 3 yrs (86% in both groups) Increase in DFS in CLND group (68% vs. 63% p =0.05). Higher lymphedema in CLND group (24% vs. 6%) 1. Faries MB et. al 376:2211-2222, NEJM 2017

84. Medical Treatment Radiation Therapy Chemotherapy Biologic therapy (IFN-a, IL-2 until 2011) Ipilimumab/ Yervoy (T cell activator) Pembrolizumab / Keytruda (T cell activator) Vemurafenib/ Zelboraf (BRAF inhibitor) Dabrafinib / Tafinlar (BRAF inhibitor) Trametinib / Mekinist ( Mek 1/2 inhibition)

85. 11 Possible Medications

86. Surgical Treatment

87. Decreasing the Mortality Rate of Melanoma

88. Summit Medical Group MD Anderson Cancer Center Prevention Detection Well informed patients Well trained dermatologist Diagnosis Dermatopathologist Treatment Integrated team: dermatologists, surgeons, pathologists medical and radiation oncologists, genetic counselors

89. Thank you