Question:
I had a 1.5 mm melanoma lesion removed recently (one cm margin
excision). There's no indication that the tumor was not localized. This
puts me at a Clarks level III/IV, Stage I/II. My doctor (GP) is
recommending going to a surgeon to have a 3 cm margin excision, then
quarterly followup skin/lymph node checkups. Questions:
1. My research on the net suggests that 2 cm is recommended, especially
to avoid skin grafts. Larger margins offer no improvement. Agree?
2. Since I am borderline stage II, should I be considering any of the
following?
a. a referal to an oncologist
b. a blood test (would it do any good?)
c. xrays (would they do any good?)
d. other tests to see if it metasticized? e.g. MRI, c-scan, gallium
scan
e. lymph node mapping or sentinel node removal (note tumor has
already been excised)
f. a second opinion on the blood test
g. inclusion in a vaccine trial, e.g. JWCI
h. other types of extrinsic or intrinsic treatments
Answer:
You've asked a number of interesting and difficult question.
Most surgeons would be comfortable with a 2cm margin, and perhaps even
a good 1 cm margin -- just pick a surgeon with experience in dealing
with melanoma (perhaps a plastic surgeon).
As an oncologist, I always encourage referal for piece of mine if you do
not believe your physicians know how to treat this disease -- but a
medical oncology opinion really isn't needed in this case.
There are no melanoma specific blood tests of value; however I would get
a blood count and chemical profile as a general screen. X-rays would be
indicated only if you have abnormal physical findings or symptoms to
suggest metastasis (or if the screening profile is abnormal). I wouldn't
argue with a physician who felt a chest X-ray at this point was
indicated. Other fancy X-rays are of no value (remember in melanoma,
early detection of metastatic disease does not change the overall
prognosis).
Lymph node excision (with or without sentinal node biopsy) is a heavily
debated point. This month, the American Society of Clinical Oncology
released the education booklet accompaning their annual session (which
begins tomorrow). One presentation indicated that patients with 1 to 3
mm. thick melanoma are the most likely to benefit from a traditional
lymph node removal (benefit defined as improved survival). You would fit
this group and thus should consider nodal excision. There are trials of
sentinal node excision, but a definative answer is not yet available.
A vaccine or immunomodulatory trial is a consideration, but don't be
suprised if the trial offers a control arm of no or sham therapy
(necessary to determine if the vaccine is of value in preventing
recurrance).
Finally, you sound as if you are at risk for new lesions -- you should
be closely followed by a physician who can recognize melanoma and has
the time to scan your skin from head to toe. This can be a
dermatologist, an oncologist, or your general practicioner (who sounds
like he/she knows what he is doing!)
