Our trip to the University of Pennsylvania was valuable in two ways. We got a good synopsis of Robert’s melanoma – what’s positive, what’s negative, what’s the bottom line. And, we got a run-down of all the options for treatment, including some we hadn’t heard about before. We have one more piece of information to put into the mix, and then we’ll be ready to decide what’s next.
The Stanford report added some details, and Dr. Schuchter explained them to us. On the plus side:
- The pathologists saw tumor-infiltrating lymphocytes in the melanoma, meaning that Robert’s immune system was trying to eliminate it.
- They called the patterning of the lymphocytes “brisk,” which is good – it means there were a lot of them.
On the downside:
- The tumor had a high mitotic rate – five dividing cancer cells in a square millimeter of tissue (5/mm2). That means it was growing and adds to the risk.
The most important factor, as we’ve known, is that this tumor was thick – 9.5mm. Any melanoma bigger than 4mm is considered high-risk, and the size alone is enough to mean that the patient has Stage II disease. Dr. Schuchter said the thickness and high mitotic rate present in Robert’s case “trump” the other factors, including our old friend NED (no evidence of disease, or the absence of any sign that the cancer spread beyond the top of his head).
The worry is that this big, deep, mitotically active tumor may have given off some micrometastases before it was excised. We have no way of knowing whether it did.
Dr. Schuchter said many people with Stage II disease and melanomas this big choose the “watch and wait” option. For at least the first year or two they have skin examinations with a Wood’s lamp every three months and PET/CT scans every six months to a year to find any evidence of metastatic disease as early as possible. The biggest risk of recurrence is in the first three years, so the stretch between observations lengthens after that. After five years the examination frequency drops to annually.
For those who want to be more proactive, there are only a few options at Stage II. The chemotherapy agents now available, most notably forms of interferon, have not improved the outcomes enough to outweigh their nasty potential side effects. A promising new drug, ipilimumab, is not yet approved for Stage II, and while its side effects are not as bad as those seen with interferon, they are can be severe.
Researchers have been working on different types of cancer vaccines for a number of years. One is the GVAX vaccine being used in the trial at Johns Hopkins that we have been talking with Dr. Sharfman about (see Another perspective on the vaccine trials, 7/24/2012). Another ongoing trial, at the University of Virginia, is testing a melanoma peptide vaccine.
Dr. Schuchter said she prefers a vaccine trial for someone with Stage II melanoma rather than ipilimumab because of ipi’s side effects. She will find out whether the peptide vaccine trial includes Stage II melanoma patients, and if so, we will give that option full consideration.
Meanwhile, Robert is on the list to be screened for the Hopkins trial. Dr. Sharfman said it would be a few weeks before they are ready to begin, as they enter new subjects into the trial one-at-a-time. We’ll update you here when there’s more to say.