Treat head, neck melanomas aggressively

Tampa, Fla. - The current prognosis for head and neck melanoma is poor; therefore, the condition should be more aggressively treated, says a clinician speaking at the Second Annual Florida Melanoma Symposium at the University of South Florida.

"These melanomas do worse than those on other parts of the body," says Dr. Matthew Kienstra, assistant professor and division director of Facial Plastic Surgery and the Cutaneous Oncology Program at the H. Lee Moffitt Cancer Center, University of South Florida. "We don't know why that is. We need to be more forceful in removing the primary tumor and more aggressive with lymph node sampling and lymph node dissection in order to control disease on a regional level."

There are no "hard and fast" rules in removing these melanomas, according to Dr. Kienstra. He says these melanomas need to be treated on a case-by-case basis, taking into account factors such as tumor location and characteristics.

One of the challenges with the condition is that the nodal draining beds at risk for regional metastasis are not well defined, making lymphoscintigraphy less reliable, according to Dr. Kienstra. In particular, at risk nodes include submental, submandibular, preauricular/parotid, jugular, occiptal, posterior cervical, retroauricular, jugulodigastric and supraclavicular, as well as various combinations of these.

However, a study published in 2003 in the Annals of Surgical Oncology found that preoperative lymphoscintigraphy and a meticulous preoperative search for blue/radioactive nodes can improve results in head and neck melanomas. The study compared sentinel lymph node biopsy for head and neck melanomas, truncal and extremity melanomas. Another retrospective series published in the Archives of Otolaryngology and Head and Neck Surgery found preoperative lymphoscintigraphy to be an important step to ensure complete removal of sentinel lymph nodes.

Staging is crucial to successful treatment in head and neck melanomas. Stage I of the disease is treated with excision at the primary site. The margins for excision are 1 to 2 cm at the primary site. Similarly, stage II is treated surgically, with the potential of lymph node dissection or lymphoscintigraphy with sentinel lymph node biopsy. Stage III and IV disease is treated with excision, node dissection and radiation and/or chemotherapy. The cure rate for early stage disease is much higher than for more advanced stage disease. Dr. Kienstra notes that surgeons use the 2001 American Joint Committee on Cancer staging to determine the severity of the melanoma.

"One of the more traditional drugs in chemotherapy has been interferon," Dr. Kienstra tells Dermatology Times. "There has been a lot of focus on vaccine therapy and immune modulators such as Interleukin-2 or GMCSF. There is also standard chemotherapy such as cisplatin. At this point, we haven't found any drug therapies that are tremendously effective. A number of trials are ongoing to determine the efficacy of the agents in combination with surgery."

If the melanoma presents with features such as regression, ulceration, high mitotic rate, or it is a thick melanoma, and especially if it exhibits more than one of these characteristics, Dr. Kienstra recommends more aggressive treatment with lower threshold for node dissection. In the head and neck area, node dissection carries a risk of putting nerves, vessels and other tissues at increased risk of damage. Nodal dissection can be performed with identification of important structures to limit morbidity, but it is a more involved procedure, Dr. Kienstra notes.

Since the area of the body is cosmetically an important one, it is key to treat the condition effectively.

"It carries morbidity in terms of the ability of the individual to interact socially," Dr. Kienstra notes. "It can be painful, and surgery can be deforming. Reconstruction of the defects is an issue."