How fatal is my melanoma ?

Assessing the relative risk of death from details of a primary melanoma

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Breslow thickness

Node  US / FNA
##

Trunk location and / or ulceration in primary tumour

% 5-year survival range estimate @@

      1mm

Negative

Neither

96+

One

93 - 95

Both

85 - 89

Positive

Neither

90 - 92

One

81 - 84

Both

72 - 75

1.5mm

Negative

Neither

93 - 95

One

90 - 92

Both

90 - 92

Positive

Neither

85 - 89

One

76 - 80

Both

67 - 71

2mm

Negative

Neither

90 - 92

One

85 - 89

Both

81 - 84

Positive

Neither

81 - 84

One

72 - 75

Both

61 - 66

3mm

Negative

Neither

85 - 89

One

76 - 80

Both

67 - 71

Positive

Neither

72 - 75

One

61 - 66

Both

Less than 60

4mm

Negative

Neither

81 - 84

One

72 -75

Both

61 - 66

Positive

Neither

67 - 71

One

Less than 60

Both

Less than 60

5mm

Negative

Neither

76 - 80

6mm

Negative

Neither

72 - 75


 

## Ultrasound and FNA requires usage of the “BERLIN” criteria to maximize accuracy. (1) Oude, Verhoef et al. Eur J Surg Oncol Aug 2017   (2) Voit, van Akkooi et al. Ann Surg Oncol Dec 2017. Alternative is sentinel lymph node biopsy (SLNB) when Berlin criterion US / FNA is not available. SLNB is also appropriate when US is positive but subsequent FNA is negative.

@@ % 5-year survival in the ABSENCE of known distant metastases and in the ABSENCE of adjuvant DRUG therapy. Drug therapy, when indicated may include:  BRAF / MEK therapy, PD1 therapy and / or Ipilimumab   

@@ METASTASES Patients with known distant METATSASES have a 5-year survival of less than 60% 


 

How to use this chart?

This chart is designed to assist patient education and counselling when managing individual melanoma patients. 

We recommend physicians show this chart to patients to demonstrate where the severity of their tumour fits into the overall range.

Drugs have a role in prolonging life in high risk melanoma patients. The higher the risk, the more solid the evidence for consideration of melanoma drugs. Note that rather than basing a decision for further treatments based on one or two risk factors, this chart factors the most important five independently identified risk factors; breslow thickness, metastases, nodal involvement, primary site on trunk and ulceration. 

There are many questions now about usage of adjuvant drug therapy.

1) Do we need to do a sentinel lymph node biopsy (SLNB) to diagnose early nodal disease?

- No. The August 2017 edition of Eur J Surgical Oncology published the long term data comparing US / FNA to detect early nodes compared to SLNB. SLNB is only needed when US shows abnormalities but the FNA remains negative. The "Berlin" criteria is idealy used when effecting the U/S. 

2) At what stage do we refer a patient to a melanoma unit or medical oncologist?

- This remains unclear. The higher the risk on this scale, the more one should consider referral. Suffice to stay that at the very least all patients outside darker green zones detailed above warrant melanoma unit / medical oncology assessment. That is, any patient with an expected survival of less than 85% warrants a medical oncology opinion. Note that the key purpose of the referral is for assessment of medications rather than for any further surgery once wide local excision has been effected. Distance issues with rural patients may impact on their decisions in conjunction with their doctors.

3) Where is the risk to cost benefit in usage of drugs?

- Again we have no clear answer. Some of the drugs have concerning adverse events profiles. Some trials show severe and life threatening adverse events in over half of trial subjects. 

4) When do we consider BRAF testing?

- A patient determined to be at least 8% mortality risk justifies BRAF assessment. BRAF status can be determined from the primary tumour, a secondary, or from a blood test. The BRAF status will effect the type of medications offered and the point at which drugs would be considered. BRAF / MEK combination therapy has a lower adverse event profile than some other current melanoma drug protocols. 

Your ACCO Board expects the issues raised here will be further developed and refined in time.

© Copyright ACCO May 2019