Chapters Transcript Video Melanoma: Head and Neck Surgeon’s Perspective Back to Symposium Dr. Brendan Gaylis outlines the risks and complications of melanoma in the head and neck region. Our next speaker is uh dr galas of head and neck surgery. Dr galas is experienced in both the clinical practice and clinical research in head and neck surgery and he will talk to us about melanoma. The head next surgeon's perspective dr gales. Thank you very much. Can you hear me okay? Yes, thank you. Well first of all it's a great honor to be invited to speak today and thank you Dr Greenway and dr barrett doctor Kelly and the whole organizing team for putting on such a wonderful event over so many years. Uh It's truly a great accomplishment. Also want to thank the the back office staff uh meg Carey and and Megan and Justin and scott for for assisting me with my slides. Um and all the work that you've done in in putting this conference together. Um I'd like to acknowledge Dr Nadeem me who's already spoken whose Doctor Greenways fellow one of dr Greenways fellows this year for assisting me as well. Um I am a head and neck surgeon at Scripps Clinic. I direct the scripts. MD Anderson had an ecology program and it's truly been a pleasure to work with Dr Greenway and his entire team of staff and fellows of many years. And I thank you for your support. Mhm. So my talk today is on Hedonic melanoma and specifically the perspective of the head and neck surgeon. Um One of the advantages of talking late in the days. We've already heard a lot of a lot of important issues regarding melanoma. So I'm going to go through some of these things quite quickly. Um We'll talk a little bit about the epidemiology issues pertaining to the diagnosis. Uh the work up of patients with melanoma, the head, neck. Um Dr ross has spoken in great detail about sentinel lymph node biopsy, a little bit about tumor exculpation and adequate margins that we should be taking. And of course some of the reconstructive challenges that we have that are very specific to the head and neck area. Um So I think I might have to skip point slide. So with regard to the epidemiology, I think we all know there's been a dramatic increase in incidents worldwide over the last 50 years of malignant melanoma in in 2020 in the usa there were about 200,000 plus Cases and that's compared to in 2008 Um where there were only 62,000 cases and this is from the American Cancer Society right now. We have a lifetime risk of one in 38 people um uh of white people getting melanoma, one in 1000 for african americans and one in 100 and 67 for Hispanics of notice about 30% of all cases involved the head neck as one would expect. Um Part of the body that's probably most exposed to ultraviolet radiation. And we've heard from dr Wysong the importance of that The average age is about 59 years. Um it's not uncommon in people younger than 30 years. It affects both sexes but more common, slightly more common in males. Um there are about 60 850 deaths um that were expected from last year. Um and that's one bright sign. The mortality continues to decrease probably from a number of reasons including perhaps earlier diagnosis and of course um improvements with immunotherapy and targeted ble therapy. But despite the decrease in mortality um um it's still an extremely morbid disease and has costs over $3 billion 2020. So what are the specific challenges to the head and neck region? Um Well of course, number one cosmetic, you know this is uh the most cosmetic part of the human body and that's the part of the human body that gives us our image and um our image is an extremely important component of our identity. Um But the head neck also has some functional uh importance as well, organs of breathing, organs of speech and swallowing, organs of hearing that are very closely um um anatomically related to the skin of the head and neck. So that's another important aspect. And then of course the head and neck has a diverse lymphatic drainage which makes lymphatic um sentinel lymph node biopsy a little more tricky than other areas such as the trunk which has a more um standard lymphatic drainage supply. So regarding diagnostic biopsy of the head neck. I'm going to go through this quickly. We know that the depth of the lesion is the most important aspect we we encourage on pigmented lesions to do an exceptional biopsy with 123 millimeter margins on larger lesions that cannot be exercised by a dermatologist. It's obviously appropriate to do a punch biopsy of the thickest portion of the pigmented lesion to try and get the breeze lows depth of the lesion. We want to try avoid shave biopsy of pigmented lesions except in some of the cases that dr piggott mentioned. And most importantly uh as well is that these biopsies need to be read by experienced the matter pathologists and um we've heard from them today as well. Um Alrighty let's see here now regarding the work up. We haven't spoken a lot today about work up but I thought I'd put up some n. c. c. and guidelines from 2020 regarding what sort of imaging studies should we do on these patients and what would be the most cost effective way to work up these patients. So the current guidelines are that for stage zero Inside two melanomas, a history and physical is probably enough. Um An image should be reserved only for specific symptoms that um We are worried about the stage one a less than 10.8 millimeters no ulceration again a history and a physical is probably good enough without any imaging. Um Once we get any further than these eight millimeter deep lesions, the T. One B. S. And the T. Two A's. Um Then we we know that history and physical is essential but we have to start bringing in the role of sentinel lymph node biopsies and start to discuss this with patients. And certainly in the stage three sentinel lymph node biopsy positive patients we have to start doing uh imaging um and this may include the ct of the chest, abdomen, pelvis and memory of the brain um plus or minus a whole body pet ct scan. Um This also applies to stage three um N plus in transit lesions. Um In this particular instance we would obviously have to do a fine needle aspiration biopsy for a palpable node and cross sectional imaging. And then in stage four patients who have documented distant metastatic disease. Um An L. D. H. With cross sectional imaging is important as well. So just a reminder that we have to we have to rely on our clinical evaluation of patients taking a very good uh systemic history, their constitutional symptoms, the respiratory tract, the G. I. Musculoskeletal, Hippocratic neurological systems and base any of those symptoms to make our way to make our uh decision for further work up. Alright, sentinel lymph node biopsy of the head and neck. This is a minimally invasive procedure to identify patients harboring a cult nodal disease. Um As we've heard from dr ross. It provides us some very important staging information but it also has a therapeutic benefit for intermediate thickness melanoma by removing microscopic disease which may be the sum total of metastatic disease that patients have. And so it may also identify patients who will need closer observation and maybe a therapeutic neck dissection or immunotherapy. The sentinel lymph node biopsy may also detect a non sentinel node positivity and we know that this portends a worse prognosis and um would um Direct us to to alternative therapy. So in summary about 20% of patients with stage one and two melanomas will be upstaged to stage three. But that also means that 80% of patients will be spared any further surgery or immunotherapy and maybe just followed by close observation. Or maybe not even that close observation. So who should get a sentinel lymph node biopsy. Again this has been discussed but it's really based on the risk of regional disease. Um And the data that I that I found were that was that for patients who have a tumor thickness between 0.75 and 1.5 mm. The The risk of occult disease is about five From 1.5 to 4 mm thick. It goes up to about 20% and greater than 4 mm 35%. Um So overall 15 to 20% of the Stage one and two patients will have a cult Stage three disease and be at risk for recurrence. Our current indications according to the 2020 n. c. c. and guidelines are for doing a sentinel melanoma on most Patients who have localized disease greater than 0.8 mm thick. Or those patients who have a thinner lesion with adverse prognostic variables that include to my extension to the deep margin ulceration, lymphoma, vascular invasion, young age, high metabolic rate etcetera. One also has to consider the patients um age uh and and and risk of undergoing the general anesthetic and having a sentinel lymph node biopsy. So we will be Um certainly I will be less inclined to to be ultra aggressive on patients who may be older than 85, 90 years old and have significant co morbid medical conditions. All right. So what about the logistics of the sentinel lymph node? We usually do a lymph oh cinta graham within 24 hours of the surgical procedure. Um The imaging performed by the nuclear medicine folks are is done one after one hour after the injection. We know now that a spect CT is probably better than the traditional 2D plane. Our imaging uh in terms of the number of lymph nodes that are yielded at the time of the sentinel node dissection. Once the patients in the operating room we inject some methylene blue dye, we make a 2 to 3 centimeter incision over the area that is taken up by the gamma probe. We identify the sentinel lymph nodes, take them out and send them for permanent histological evaluation. So what we know in 2021 is it's a minimally invasive procedure identifies micro metastatic disease either by histology or PCR it would determine those patients who may benefit from further immuno from further surgery or immunotherapy or perhaps close observation. Um the morbidity is minimized but I will say in the head and neck area we have to be uh very careful. Um We have a lot of nerves in the head and neck. We often have nodes in the parody gland. We have the facial nerve branches, we have to do nerve monitoring during the surgery. And um whilst morbidity is low, it's certainly not negligible and this has to be taken into consideration. In addition, we've heard from dr ross that sentinel lymph node biopsy is not only the standard of care for melanoma but also for merkel cell carcinoma. And certainly we consider this very strongly in patients who have advanced squamous cell carcinomas that they had in there or elsewhere. And especially immuno compromised patients who have undergone prior transplantation and our uh immuno compromised. Um here's uh to the plane our image showing a the injection site and uh the uptake of of the lymph nodes. This is a right lateral done at 45 minutes at 15 minutes a left lateral, which just shows the uptake at the injection site. And this really doesn't give us any three dimensional anatomical information about the site about the exact position of the lymph nodes, it uh as you can see but with the advent with the advent of the spect CT scan, we can now do a ct scan showing us um great detail of exactly where that lymph node is. In this case it's an immediate supercar vehicular node. But we can see the the airway, we can see the thyroid gland, we can see the carotid artery and the jugular vein and so this is much more helpful to the surgeon. Furthermore. The comparisons have been done between spect ct with two D. Planar imaging and have shown a significant with significant probability um The increase in the sentinel lymph node yield um as well as the number of positive sentinel lymph nodes per patient has been improved. With the spect ct scan again, a picture of a actual surgery with a parodied lymph node with the parodied ectomy incision outlined just in case of parodied ectomy would need to be performed and um the lymph node is shown here. Um Okay I'm gonna skip that slide. We've discussed the M. S. L. T. One and M. S. L. T. To findings but very briefly there's no significant difference in survival at 10 years for intermediate or thick melanomas but we have a significant difference in disease free survival for the intermediate and thick lesions on the sentinel lymph node arm of this study. I'm gonna skip over these charts which basically show the results from the M. S. L. T. One and T. Two trials. The conclusion from the M. S. L. T. One was that it's beneficial for node positive, intermittent for intermediate thickness. Um patients are doubling of the melanoma specific survival, a doubling of distant disease free survival and a tripling of overall disease free survival. All right. So I'm going to um move on because I know time is of the essence here and um let's talk about a wide local excision um for the actual excision of the melanoma, I would say a minimal of one centimeter margin for very thin lesions. Um As we get to a thicker lesion greater than two millimeters, we recommend a two centimeter margin if possible. And in order to obtain the best margins and outcomes I apologize for the slide not being in great focus, but this just shows the lymph node drainage of the head and neck and if you draw a line right through the ear vertically. Um those skin lesions that are anterior to the ear will drain mainly to the Parodied lymph nodes as well as to the level one or perry facial lymph nodes before they descend down into the lower part of the neck post area to the oracle. Um The occipital scalp etcetera will drain to post curricular nodes, to occipital nodes and then to level five lymph nodes And then along the jugular chain to levels 2, 3 and four we know about the role of ultrasound in um in close observation so I'm not gonna speak much about that. Finally just some photographs regarding reconstructive challenges. Um And I thought I'd just show a few patient photographs. So some of these may be a little bit glory. Um I apologize, but it is the reality of the head and neck. So he has a patient who's had an excision with skull bone being uh exposed perry craniums being taken if the scalp is loose. We do have a decent chance at closing this with um two large rotation flaps, the so called 02 S. Flat. And here's the 02 S flap in size. Uh Here we have the flaps elevated on the scalp and um final closure coming together quite nicely. Um And uh this patient healed up really well. Sometimes we have more challenging scalp lesions such as this patient who had a uh at least a 10 centimeter lesion. Uh the defect with the exposed skull bone and this case could be closed by a free flat. Um But this patient had another very highly uh life threatening squamous cell carcinoma of the neck which had to be treated quite soon after this. So we decided to put on a prime matrix graft Um and allow him to heal up. And he has his healing at six weeks um with almost near complete healing. And here's his healing by three months with a complete re epithelial ization. Um Here's an example of a recurrent ear melanoma with three nodules of melanoma rickard after a wide local excision on a patient like this. We don't have any choice besides doing a total recollect to me. Um He was repaired with a full thickness skin graft. As you can see. We kept his ear canal nice and patent that he could hear very well. He actually looked extremely good from the front without any prosthesis. But he decided to get an ear prosthesis and um he's doing extremely well. Some patients like this elderly gentleman has had half his ear removed and all he really cared about was that he could wear his glasses so his pinar was preserved. And when you look at him from the front, you could not tell that anything was done. And he was not interested in any other form of reconstruction. Um Sometimes we're not able to preserve the ear canal and in this patient who has a history of multiple skin cancers. He lost his hearing and he had terrible hearing on the other side. But we were able to put a bone anchored hearing aid which provides him very reasonable hearing despite his disability. And he's a very happy camper. Finally one of the most challenging cases. I've been involved Doctor Patel a and I and he was intimately involved with this patient who had a melanoma of the nose. Um This. Uh this particular case highlights um some of the great challenges we have, not only in reconstruction but the natural history of this disease, he underwent a most reception of the nose. Um We here we here is in the operating room with dr Patel is the primary surgeon and me helping him. We we reconstructed him with a nasal labial flat for the inner lining. Uh He had his cartage graft on top of that and a foreign flag came down on that and this was about a seven hour operation. The patient um This is at the end of the surgery and this is post operatively. Um He really truly had a wonderful result. Um but unfortunately six months later he came back with the recurrence um in the flap of malignant melanoma involving the nasal septum. And the patient had to undergo this which was a total Ryan ectomy. And as um challenging and as terrible as this looks. Um we were able to reconstruct him. I'm sorry that my last slide, the last slide that I sent him showed him with his his prosthesis. And he continued to have a wonderful career as a realtor. And I called him this week. This is nine years ago and he is still alive and doing well um and was very happy to hear from me. Um So I thank everybody for all of those patients for allowing me to present their pictures um in conclusion, um with respect to staging H and P. Alone for stage one and two rely on symptoms to guide imaging full body cT scan, MRI or pet for gross regional and distant disease, sentinel lymph node biopsy remains the most sensitive and specific staging modality. It's safe, it's reliable and it can include the paraded bed, either a complete lymph node dissection and or immunotherapy for stage three disease, systemic therapy for stage three and four disease. Most importantly, let's present all these patients at a multidisciplinary tumor board with expert somatic pathology. Let's get our adequate margins. And of course, the challenge of reconstruction remains. Thank you for your attention. I hope I didn't go over too much. Published August 16, 2021 Created by Related Presenters Brendan Gaylis, MD Facial Plastic & Reconstructive Surgery Scripps Clinic Dr. Brendan Gaylis treats patients for diseases and disorders of the ear, nose and throat as a head and neck surgeon at Scripps Clinic. View full profile
