Smilow Shares with Primary Care: Melanoma

May 03, 2023

Information

May 2, 2023

Presentations by:

Harriet Kluger, MD, Kelly Olino, MD, FACS, Thuy Tran, MD, PhD, Flora Zarcu-Power, MD, Jonathan Leventhal, MD

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00:00Hello, Welcome to Smilo shares
00:03with Primary Care. I'm Karen Brown.
00:05I'm an internist in North Haven and the
00:08Medical Director of the Primary Care
00:10Service line of Northeast Medical Group.
00:13And I am joined normally to
00:16cohost this series with Ann Chang,
00:19who is not here and Kevin Billingsley,
00:22who's here and is the CMO of Smilo.
00:26We will introduce our speaker shortly.
00:28After an orientation to this
00:30session in general,
00:31today's topic is Melanoma.
00:33This is a monthly series designed to focus
00:37on primary care perspectives of cancer,
00:40especially diagnosis and handoff where
00:44we are involved and the designated
00:47audience is primary care clinicians,
00:50although I think many clinicians
00:52can learn from this.
00:53And we always have at least one
00:56primary care clinician along
00:57with SMYLO clinicians and often
01:00focused in one geography.
01:02This one is is not so much focused
01:05in one of our geographies and
01:08we hope that this will help us
01:10all become better at what we do.
01:12So we will go and we'll have a
01:15introductions and then we have
01:18a three case presentations.
01:21And we will learn through our
01:23case presentations and leave
01:24time for questions at the end.
01:29So at this time, I would like to introduce
01:32my NEMG primary care colleague, Dr.
01:35Flora Zarku Power Doctor.
01:39Zarku Power is a graduate of the University
01:42of Medicine Carol Davila in Bucharest,
01:44Romania, and she completed her
01:46internal medicine residency in New York
01:48Presbyterian Hospital in Queens, NY.
01:51She initially joined the staff of
01:54Yellow Haven Hospital as a hospitalist
01:56before starting her practice in Milford.
01:59She's now a practicing physician and
02:01also a managing partner of Primed,
02:03which is a PS:,
02:05A within Northeast Medical Group.
02:08She's been an active member of the Milford
02:10and Bridgeport area medical community,
02:12and she's been on the executive medical
02:15staff committee at Bridgeport Hospital.
02:17And is completing A2 year Emerging
02:19Leaders program through the
02:20Yale School of Management.
02:22She's an active clinical leader in
02:24Northeast Medical Group and lends
02:26her expertise to the NEMG Primary
02:28Care Steering Committee and also the
02:30Yale New Haven Health System Care
02:32Signature Pathway Work Doctor Zarku
02:34Power strongly believes in a patient
02:37doctor relationship as the keystone
02:40to great health outcomes and that
02:42a relational care team approach
02:45is paramount to effective care.
02:47Kevin,
02:47I'll turn it over to you on to introduce
02:50the members of yours Milo team.
02:53Karen, thank you.
02:55I'll just say it's really a
02:57pleasure for me to be here.
02:59I as you alluded to my associate Dr.
03:03Ann Chang generally partners with
03:05you in this wonderful venture.
03:08But I'm absolutely delighted
03:09and honored to be here.
03:11I'm a surgical oncologist and I service
03:14the Chief Medical Officer of the.
03:16Smilo Cancer Hospital
03:17and Health Cancer Center.
03:19And I will say on a personal note,
03:21I am just delighted to see
03:25this initiative moving forward.
03:27Those of us who are oncologists and
03:30are treating cancer patients regardless
03:32of our discipline are so indebted
03:35and tied to our primary care partners.
03:39It is really kind of the teamwork,
03:43the collaboration and the.
03:45The seamless flow of care between
03:49the primary care environment and the
03:51specialty environment that leads
03:53to great cancer care outcomes not
03:55only in the early diagnosis and in
03:57the support of the treatment phase,
03:59but in the survivorship phase.
04:01So I I think that this is really
04:05a valuable exercise and I'm.
04:07Hoping that that people are enjoying
04:10it and and taking a lot away from it,
04:13it's it's an honor for me to introduce
04:17several of my Smiley Smiley colleagues
04:19all of whom are esteemed experts
04:22in their field field and I'll I'll
04:26just start with Doctor Harriet Kluger.
04:29It would not be an exaggeration to
04:32say Doctor Kluger is a international
04:35authority in Melanoma and cutaneous oncology.
04:38She is the Harvey and Kate Cushing
04:40Professor of Medicine and the
04:42leader of the Melanoma program.
04:43Here at Smilow,
04:45she sees patients with both
04:47Melanoma and renal cell cancer.
04:49She has an extensive research portfolio
04:52with an interest in developing
04:54new drug regimens and biomarkers.
04:57That are predictive of response
04:59to therapy and Melanoma.
05:01She participates in a variety
05:03of clinical trials.
05:05She directs an active research
05:07laboratory that studies tumor and
05:09immune cells from patients treated
05:11with these novel therapies to
05:13determine mechanisms of resistance.
05:15Her laboratory also completes
05:17preclinical studies to improve treatment
05:19regimens for patients with Melanoma,
05:21renal cell cancer,
05:22and brain metestes.
05:26You know Harriet is definitely our go to
05:29expert and I think we'll find her just
05:32a fountain of knowledge in this regard.
05:35Next it's a pleasure for me to to introduce
05:37one of my surgical partners, Doctor Kelly.
05:40Olino Kelly is a W Board certified surgeon
05:43who provides patients comprehensive
05:45surgical care for skin and soft
05:48tissue tumors including Melanoma,
05:50markle cell cancer, sarcoma,
05:52basal cell cancer and others.
05:55She's been a recipient of a number of
05:58awards including the Society Surgical
06:01Oncologist Clinical Investigator award
06:03and she has funding through the Calabresi
06:06Immune Oncology Scholar program.
06:08She currently serves as the NCCN Non
06:12Melanoma cutaneous on the cutaneous
06:14malignancy committee and she's
06:16a great clinical surgeon.
06:19Next doctor Twee Tran.
06:20Twee is an assistant professor of Medicine.
06:24She cares for patients with
06:26Melanoma and other skin cancers at
06:28our spinal cancer hospital sites,
06:30both in New Haven and in Guilford.
06:34She is a graduate of the A/B IM Physician
06:37Scientist Research Pathway, and Dr.
06:40Tren is a bit of a a Yale product.
06:43She did both her internal medicine
06:46residency and her fellowship here at Yale,
06:49although she received both of her.
06:52Both her PhD and her MD degrees
06:56from Vanderbilt.
06:57She's also very involved in research,
06:59including novel therapeutics
07:01and drug combinations,
07:03and is a participant in the
07:06Yale skin Cancer spore.
07:08She's a principal investigator
07:11of several clinical trials.
07:13Last and certainly not least, Dr.
07:15Jonathan Leventhal is an associate
07:18professor of dermatology.
07:20And is the director of the
07:23SMILO Onco Dermatology Program.
07:26Doctor Leventhal received his
07:28bachelor's degree and medical degree
07:31at the NYU at NYU and then came here
07:34to Yale for additional training,
07:36where he served as a chief resident.
07:39His specialty is in providing care
07:42to skin cancer patients who develop
07:45cutaneous toxicities from their treatments,
07:47as well as diagnosing and treating
07:50skin cancers.
07:51Like many of the other panelists this
07:53evening, he leads clinical trials,
07:55studying new treatments for
07:57managing dermatologic toxicities.
07:59And he's actively involved in residency
08:02in medical education as well as
08:05serving as an editor for the textbook
08:07self-assessment in dermatology.
08:09So do you really have an
08:12outstanding cast of experts here?
08:14And I'll turn it back to you, Karen.
08:18Great. Let's get started. Florida,
08:21you want to present the first case.
08:23Karen, thank you for the warm introduction.
08:25I want to say your work
08:28and really unsailable.
08:29I'm probably then honored also to have
08:30the support of our colleagues. It's Milo.
08:33I'm going to start presenting the first
08:38case patient who came in reporting
08:41an enlarging leg mole situation that
08:43we encounter in practice quite often.
08:46I'm sure my colleagues will recognize it.
08:49This is a 59 year old healthy white
08:51female with a past mental history
08:53of hypertension hyperlipidemia.
08:54She has a history of having used
08:57tanning beds a few decades ago.
08:59She wasn't seen for about 3
09:01years due to a COVID pandemic.
09:04She reported a skin lesion about a year ago
09:07and notably enlarging her family history,
09:11is remarkable for her mother
09:14with a history of Melanoma.
09:16So I just wanted one more second
09:19probably to take a look at the lesions,
09:21so my colleagues could pay
09:22attention to some of the features
09:24that associate to this lesion.
09:28And we'll in a moment we'll discuss
09:31actually the ABCD's of recognizing
09:33the warning signs of Melanoma.
09:35So this would be sort of a
09:36a good picture to remember.
09:40We could move on to the next slide.
09:41So talking about moles and early signs
09:44of skin cancer, couple of specifics,
09:47what do we look for when we have a patient
09:50in front of us and we do a skin exam,
09:52we're looking for anything new or changing
09:55on both sun exposed and sun protected areas.
09:59Typically Melanoma appear in women
10:02on the legs and number one place
10:05they develop men is on the trunk.
10:08They could arise though anywhere on the skin,
10:10even in the areas where sun doesn't shine,
10:12so beware.
10:14Generally speaking, most moles,
10:15brown spots and growths on the skin
10:17are harmless, but not always.
10:22Here's the ABCDI was talking about.
10:25This is a simple guide to recognize
10:27the warning signs of Melanoma.
10:28A is for asymmetry, and if you draw a
10:31line through the middle of the lesion,
10:35the two halves don't match.
10:38B is for border.
10:39Typically they tend to be uneven.
10:42They may be scalloped or notched.
10:44C is for color.
10:46Multiple colors are a warning sign
10:48and melanomas may may have different
10:50shades of brown, tan, or black.
10:52D is for diameter.
10:54It is a warning sign if a lesion is larger
10:57than 6 millimeters or quarter of an inch,
11:00and any lesion that's darker
11:02than others not to be overlooked.
11:05One exception is the amylanotic melanomas,
11:08which are colorless,
11:10is for evolving any change in size,
11:14shape, color, or elevation of a spot.
11:17Any new symptoms of itching, crusting,
11:20bleeding, maybe warning signs?
11:23Also, look for an ugly duckling.
11:26The strategy is based on most
11:28malls resembling one another,
11:30while melanomas stand out
11:31like an ugly duckling.
11:40Jonathan, do you want to take over?
11:42Absolutely. It's a pleasure to be here,
11:44really happy to participate
11:45in Smile Shares Primary care.
11:47So I'm going to briefly highlight some
11:49of the main subtypes of a Melanoma,
11:52so superficial spreading as
11:53you can see on the top left,
11:55these are the most common types of Melanoma.
11:57You can see a lot of the features
11:59of the Abcd's from the last slide.
12:02And they tend to grow radially pretty
12:04slowly over the course of months to
12:07sometimes even years before then growing
12:09vertically and penetrating more deeply.
12:12Now this is in contrast to
12:13the nodular type of Melanoma,
12:15which tends to be far more aggressive
12:17and that these can grow quite rapidly
12:19and they tend to to present more deeply
12:22in the dermis at a higher stage.
12:24So these are important.
12:25You know,
12:26it's talking to patients about any
12:28recent change or rapidly growing skin lesion.
12:31The lentigo and malignant subtype
12:32tends to occur in elderly patients.
12:34Often looks like an atypical lentigo
12:37or a sunspot that elderly patients
12:39might develop in sun exposed
12:41areas but with atypical features.
12:43Probably the most challenging one
12:45for anyone to diagnose are the
12:48amylonotic types of Melanoma,
12:49and these tend not to have pigment,
12:51they're often pink and.
12:53Patient history can be very important
12:55here with a new amylonotic lesion
12:58that's either rapidly growing
12:59or symptomatic in some way such
13:01as being painful or bleeding.
13:03And then finally the acryl,
13:05intigenous and subungal types
13:07are important particularly in
13:08patients with darker skin types.
13:10They might be have a higher risk of
13:13developing this type and if that's
13:14why it's important when examining
13:16patients to look at the palms and soles.
13:18And regarding subungal Melanoma,
13:20these typically present with Melaninicia,
13:23which as you can see is a melanotic band
13:26that grows from the proxable nail upwards.
13:32I think it's important to have a
13:35differential diagnosis anytime
13:37you approached pigmented lesions.
13:40So I highlighted here on this
13:41slide what I think of as as
13:44the most clinically important,
13:45so I would say by far.
13:48The most common presenting diagnosis
13:50that that comes in with concern for
13:54Melanoma are seborrheic keratoses,
13:56which are on the the top left.
13:59These are stuck on waxy tan to brown
14:01or even darker brown black papules
14:03and plaques that tend to develop
14:06and patients as they get older,
14:08and sometimes they can be very challenging
14:11to distinguish from a Melanoma.
14:12So dermatologists use dermatoscopes.
14:14And if we are unsure,
14:16we'll perform a skin biopsy,
14:18certainly on the top right,
14:20we always consider normal appearing nevi
14:22and those that are slightly dysplastic.
14:25So they're not fully normal appearing.
14:28They might be slightly asymmetrical,
14:30borders are irregular,
14:31but these don't meet criteria for Melanoma.
14:34And when these are biopsied,
14:35they're not Melanoma then on the bottom left.
14:39Illustrates the fact that even non
14:41Melanoma skin cancers can be pigmented.
14:43So this is an example of a pigmented
14:45basal cell carcinoma noted as a slightly
14:48more pearly appearance to it and with
14:50a dermatoscope you might see other
14:52features of a basal cell on the the bottom.
14:55Middle picture is an example of vascular
14:59lesions such as angiokeratomas or angiomas.
15:02Sometimes they can have
15:03a really dark purplish,
15:04even blackish hue and can be challenging.
15:07As dermatologists,
15:08we can use a dermatoscope which
15:10you can see in the top right
15:12corner highlighting those vascular
15:13lacunae and that's reassuring.
15:15And then on the bottom right
15:17is a picture of a blue Nevis.
15:18And so these moles can also appear in
15:22as differential diagnosis of Melanoma,
15:25but they are benign.
15:29I just wanted to briefly
15:31review the epidemiology.
15:32Everyone here is familiar with Melanoma.
15:35I wanted to highlight that most
15:37cases actually occur on de Novo,
15:40although some might develop from
15:42a precursor lesion and these are
15:45typically either a congenital
15:46Nevis or an atypical Nevis that
15:48the patient has that then changes.
15:50It can occur in anybody,
15:52but tends to tends to predominant
15:55in white men over age 50.
15:57And then interestingly,
15:59underage 50 women outnumber men,
16:02likely due to tanning habits.
16:04It also is a diagnosis of young patients.
16:07And regarding survival,
16:08some factors associated with poor
16:10outcomes include elderly male patients,
16:13those who have darker skin types,
16:14likely because of the more
16:17aggressive biology and presentation
16:18of the equal indigenous Melanoma,
16:21as well as patients who are immunosuppressed.
16:25I very want, I very briefly wanted
16:27to provide an overview of the
16:29main risk factors for Melanoma.
16:30So like any cancer we can consider
16:33those that are environmental and those
16:35that are hereditary. Next slide.
16:39So for the environmental risk factors
16:41it's it's really all ultraviolet
16:43exposure and so we know that intermittent
16:46intense sun exposure throughout life
16:48and increase the risk of Melanoma.
16:49As well as sunburns,
16:51and not just childhood sunburns,
16:52but also sunburns that occur
16:54cumulative cumulatively through
16:56adolescence and adulthood.
16:57And finally,
16:58especially in young women,
17:00tanning beds have been associated
17:02with increased odds of Melanoma.
17:06And now I'll discuss some of
17:08the hereditary risk factors.
17:09So having decreased melanin and increased
17:12tendency to burn such as fair skin,
17:15freckling, blonde hair, red hair,
17:16light eyes are all associated with Melanoma.
17:19In addition, having an increased
17:21number of pigmented lesions,
17:22the important one here is having
17:24over 100 nevi that really increases
17:26the risk of developing Melanoma.
17:28And I think it's important to have
17:30an idea of these inherent risk
17:32factors because the United States
17:34Preventative Services Task Force does
17:36not recommend screening everybody,
17:37But it's important to keep in
17:39mind those who have phenotypic
17:41risk factors for Melanoma as well
17:43as personal or family history.
17:45Next slide.
17:48So having a history of skin
17:49cancer increases your risk of
17:51developing subsequent skin cancers,
17:53and this is true for Melanoma.
17:54As well as having a first
17:56degree relative with Melanoma,
17:57there are also genetic syndromes of
18:00kindreds who have Melanoma passed
18:02on from generation to generation.
18:04The most important one to know about
18:07clinically and the most common is the
18:10familial atypical multiple Melanoma syndrome.
18:12So these patients have hundreds of
18:14dysplastic appearing nevi and they're at
18:16increased risk of developing Melanoma,
18:18but also pancreatic cancer.
18:20And I think it's important to keep in mind
18:24who to think about screening for genetics.
18:27So we shouldn't send everyone
18:28who has a family history.
18:30So you want to keep in mind patients
18:32who have several members on one
18:34side of the family with a Melanoma
18:36or if a family member had more than
18:39one Melanoma and in particular.
18:41Anyone who comes from a family that has
18:43both Melanoma and pancreatic cancer,
18:45that should be an important clue.
18:48And we have seen many patients
18:50who have had several skin cancers,
18:52including melanomas.
18:53But you really want to think
18:54about those that have had over 3,
18:56three or more melanomas,
18:57especially if the first one
18:59happened when they were young.
19:01So I'm now going to turn it
19:02over to my wonderful colleague,
19:04medical oncologist Dr.
19:05Tran.
19:05To discuss how do we follow patients,
19:08especially those with low risk melanomas,
19:10Dr.
19:10Tran,
19:10thank
19:11you so much, Dr. Leventhal.
19:13So we typically see all Melanoma patients
19:15and follow up in medical oncology.
19:18And so we we typically follow these
19:20individuals for at least five
19:22years after their Melanoma surgery.
19:24Presuming that it's an early stage Melanoma,
19:26prognosis is typically very
19:28good with close surveillance.
19:29And we see these individuals,
19:31depending on their stage either every
19:33six to 12 months for the next five years
19:35and then subsequently at that point
19:37considered handing over the reins to
19:39primary care for ongoing surveillance.
19:41And every visit we check
19:43complete blood cell count,
19:45metabolic panel and an LDH as a
19:48surrogate tumor marker that we can
19:51assess for early Melanoma recurrences.
19:53And depending on the stage as well,
19:55for these early stage individuals,
19:57consider getting an either an
19:59annual chest X-ray or CAT scans.
20:01I think what's really important
20:03and helpful is that if the primary
20:06provider determines that there
20:08is any suspected new symptoms,
20:11any worrisome symptoms concerning
20:13for distant recurrence,
20:15we should always keep in mind to have a
20:18low threshold for ordering additional
20:20imaging and if possible for early diagnosis.
20:23After five years,
20:24and during that time as well,
20:26we always have to consider age appropriate
20:30cancer screening and continue full
20:32body skin checks with the dermatologist.
20:39I'll take over and I'll introduce case two.
20:42We are presented here with a 76 year
20:45old male who has a right forearm
20:48lesion noted about a year ago he denied
20:52any recent change in pigmentation of
20:54the lesion or rapid recent growth.
20:57He underwent a shave biopsy and
21:00pathology report revealed Melanoma,
21:02breast load thickness 2.3 millimeter.
21:06He reported a history of blistering sunburns.
21:09No history of tanning, but use.
21:12He does not have a history of Melanoma.
21:14His family history is also negative
21:15for Melanoma or non Melanoma,
21:17skin cancer and he retired from finance.
21:22On physical exam,
21:23he didn't have any evidence of
21:25lymphadenopathies and his skin exam
21:27on the biopsy site of the right
21:29forearm showed no signs of infection,
21:31no residual pigmentation,
21:32no nodularity, no satellite lesions.
21:36Next slide please.
21:38So this case,
21:40as you've heard earlier as
21:41Jonathan presented,
21:42is actually a nodular Type A lesion Melanoma,
21:50so.
21:50But this type requires a wide local
21:53excision to to treat the primary lesion.
21:55The probability of nodal
21:58micrometastasis is approximately 20%.
22:01The work up will include labs just X-ray,
22:04EKG if needed.
22:06Depending on the remainder of
22:09the history and lymphosyntography
22:11there is an indication for Sentinel
22:13node biopsy to determine staging
22:15and future therapy decision.
22:16In this case I'll turn it on to.
22:21Our colleague to discuss further.
22:24Hi,
22:24I'm Kelly Olina,
22:25one of the surgical oncologist and I have
22:28the pleasure to work with doctors Kluger,
22:30Tran and Leventhal on an everyday basis.
22:33So you know a lot of times when
22:35the patients first come in again,
22:36they come in really scared and that's
22:38really how we meet most people.
22:41They come in very uncertain.
22:43So again part of this is also to
22:45empower the primary care doctors
22:46on the line who know these patients
22:48inside and out and you know are more.
22:50More than just their doctors,
22:52you know, I think you guys really
22:53know the the person just as well as
22:56any doctor can know their patients.
22:57So, you know,
22:58when patients come in to see me,
23:00the first thing that we do is we,
23:01you know,
23:02we explain to them how the depth
23:04of their Melanoma really impacts.
23:06But there's certain principles
23:07that we stick to no matter what.
23:09So we talked about removing the Melanoma.
23:11We're not just removing the skin,
23:14we're removing the skin.
23:15We remove also the fatty tissue
23:17that that carries the lymphatics
23:19through which Melanoma cells.
23:20Can escape and it's actually based
23:23upon doing multiple trials that have
23:26been actually honed down studying
23:28thousands of patients over the year.
23:30Interestingly,
23:30in our attempts to make sure that the
23:33surgery becomes less and less morbid,
23:36we actually are now part of an
23:38international trial called the Melmark trial.
23:40So if any of your patients are coming in
23:42to see myself or Doctor Clune in our program,
23:45you may hear this,
23:46the mention of this trial.
23:47But again we're down to taking
23:49out about 1 to 2 centimeter.
23:51And that's really directly proportional
23:52to the depth of the Melanoma next,
23:58so you know. Laura had alluded to
24:02in this patient, you know we would
24:04strongly recommend you know this
24:06patient within the criterion of who
24:08benefits from having a Sentinel node.
24:10And again in these patients we do
24:12a full lymph node exam and when we
24:15do not detect any palpable disease,
24:17we then say do they have microscopic disease.
24:20Now just with any test that we would
24:22order if the patient isn't medically
24:24fit or if we're not going to act upon
24:27the additional staging information,
24:29I would never recommend that we
24:30do a procedure.
24:31Unless we're going to do
24:32something with that result.
24:33So for patients who have no high
24:36risk features in a thin Melanoma
24:38less than .8 millimeters,
24:40their lymph node risk is actually
24:41lower than the risk of the procedure.
24:44So we don't usually offer it in that setting.
24:47There's a newer indication of these
24:49in between .8 and 1 millimeter where
24:51we begin to have that discussion.
24:53But again, this continues to be a Gray area,
24:56the 1 to 4 millimeter.
24:58Range and even I would say the
25:00greater than 4 millimeter,
25:01I really do push patients because
25:03I do feel this information is
25:05incredibly important.
25:06There's some nomograms that you
25:08can direct your patients to or
25:09look up yourself Out of curiosity,
25:11one more mimics the population
25:12we see in Connecticut and that
25:14was developed from Memorial Sloan
25:16Kettering is now almost 20 years old.
25:18The other one is from Australia, however.
25:19Melanoma in Australia is a little
25:21bit different than what we see
25:23in the United States,
25:24so again I usually have people
25:26take a look at both,
25:27but it gives them kind of an
25:30idea where their risk is next.
25:32When we talk about what a
25:33central node biopsy is,
25:34again some principles really
25:36overlap with that of breast cancer.
25:39However, each one of us is completely unique.
25:42And I tell patients all the time,
25:43if you don't know where you're going,
25:44you need a map to get there.
25:45So that's what the lymphocentigraphy is.
25:48So we inject 2 dyes,
25:49one's a blue dye and the other one
25:51has a little bit of technetium.
25:53So it's got a little bit of
25:55radioactivity that's completely saved
25:56out of the system within six hours.
25:58And what that does is it tells me
26:00which nodal station to look for, so.
26:01In this case,
26:02it's right in the middle of the belly.
26:04And again,
26:05because we're looking for
26:06microscopic disease,
26:07we have to figure out where to go.
26:08And then what we do in the operating
26:10room is we have a little handheld
26:12Geiger counter and that really
26:13helps me hone in on which of the
26:15lymph nodes to remove next and
26:18why is that so important click.
26:22That's because it is still
26:25our best prognostic value in.
26:28Looking at recurrence and death from
26:30Melanoma and this was one of the most
26:32remarkable trials that's been done
26:33in the field of surgery for Melanoma.
26:36So even though it's an additional surgery,
26:38it gives us still more valuable
26:40information than that of some of these
26:43gene expression profile arrays that you
26:45may also have patients come in with next.
26:49And we used to actually take out all of
26:51the lymph nodes when we had patients who
26:54would even have microscopic disease.
26:56However, there were two trials,
26:57one in Germany and 1 multicenter in
27:00the United States that showed that
27:03doing this additional surgery did
27:05not improve a patient's survival
27:08specifically with their Melanoma survival.
27:11So what we do is we.
27:13We remove lymph nodes only if someone
27:15comes in and we can actually feel
27:17the lymph nodes and then there's
27:19some more selection criterion that
27:20would be a little bit more unusual.
27:22And again,
27:23the important thing is we actually
27:26now have effective treatments.
27:28So I'll next slide,
27:31so Doctor Tran will talk a little
27:33bit about this about what we
27:35call adjuvant immune therapy,
27:37which is a conversation that
27:38many of our patients now have.
27:42So as Doctor Alina had already discussed,
27:45one of the key decisions here is you know
27:48whether to pursue Sentinel lymph node biopsy.
27:51And so my next part is kind of talking
27:54about what how can we move the needle
27:57further decrease recurrence risk in
27:58these patients who may have a positive
28:01lymph node or otherwise thickened
28:03melanomas or ulcerated melanomas which
28:05have a higher risk for recurrence.
28:08And so this this chart just kind of
28:11displays for the five year Melanoma
28:13specific survival for the higher risk
28:15stage twos which are included two B's and
28:18two C's as well as the stage 3 melanomas.
28:21And as you can see there are actually some
28:24subsets of stage 3 melanomas that do much
28:26better than the higher risk stage two events.
28:29So for stage 3A melanomas,
28:31the five year Melanoma
28:33specific survival is 93%.
28:35And so compare that to a stage 2C where
28:38the where that survival decreases to 82%.
28:42So when you talk about
28:44adjuvant immune therapy,
28:45we're always talking about one additional
28:47year of some sort of systemic treatment
28:50either in the form of immune therapy
28:53or targeted therapy with the goal of
28:56trying to decrease recurrence risk.
28:58So in terms of adjuvant, oh,
29:00I'm sorry, if you could go back.
29:03In terms of adjuvant immune therapy options,
29:05there are two FDA approved drugs,
29:07temporalismab also known as Keytruda
29:09which is given every three to six weeks
29:12versus new volume M also known as Opdiva
29:15which is given every two to four weeks.
29:18Again these are all intravenous,
29:20they have similar side effect profiles
29:23and they both target the PD1 protein.
29:25To help stimulate the immune
29:28response against Melanoma.
29:29Both of these drugs are considered
29:33interchangeable in stage 2 Melanoma and
29:35as well as stage 3 melanomas In general,
29:38it's been known to have a decrease of 40%.
29:42In terms of the recurrence,
29:43however, there is no impact upon
29:47improving survival to date.
29:49Next slide.
29:51As an alternative to immune therapy
29:53for individuals with a B RAF mutation,
29:56mainly V600E or V600K mutations,
30:00which are present in about
30:02half of cutaneous melanomas,
30:03there is additional alternative
30:06adjuvant therapy in the form of B,
30:09RAF and MECH inhibitors,
30:10so drabrafnib and tremet NIB,
30:12which are both oral medications.
30:15Either given BID or daily respectively.
30:18And these medications are approved
30:20not in the stage 22 setting,
30:22but in the stage 3 setting for individuals
30:25with lymph node positive Melanoma,
30:28where it's been shown to
30:30reduce recurrence risk by half.
30:32But unlike immune therapy,
30:34it has been demonstrated to
30:36impact overall survival as well.
30:38Next.
30:41So for these individuals
30:42with higher risk melanomas,
30:44we typically again follow
30:45them closely for five years,
30:48but because of our higher
30:49risk for recurrences,
30:50we see them more frequently and we also
30:53do imaging more frequently as well.
30:55And these imaging can typically
30:57include a CAT scan of the chest,
30:59abdomen,
31:00pelvis.
31:00And I think the main point very
31:03similar to early stage melanomas
31:04is that as a primary care
31:06physician, it's always.
31:08Very helpful to screen these
31:10patients for any atypical symptoms,
31:13red new red flag symptoms because
31:15again if we can detect these,
31:17if we can diagnose these earlier
31:20outcomes are much better potentially
31:22if it's localized recurrences,
31:24they can still undergo A
31:26potentially curative resection.
31:28The most important thing even after
31:30five years is that these individuals
31:32still see the dermatologist still have
31:34age appropriate cancer screening.
31:36And while we only see these individuals
31:38for five years in medical oncology,
31:42it's so important to keep a
31:44low threshold for additional
31:45work up if there's any concern.
31:47And so the graph at the bottom here
31:49is just a representative graph from
31:52the adjuvant trials of Jabrachno
31:54Ventremett showing that at 60 months
31:57which is equivalent to five years
31:59although the recurrences plateau.
32:01There is still a few recurrences
32:04afterwards and so even despite completing
32:065 years without any recurrence of disease,
32:10there's still a possibility and so that
32:12has to be something that is factored in,
32:15particularly if a patient
32:16develops new symptoms,
32:17New lymph adenopathy next.
32:23So when we talk about individuals
32:24with high risk disease,
32:26adjuvant therapy isn't the
32:27correct answer for everyone.
32:29We have to individualize the and
32:32personalize these decisions based on age,
32:35comorbidities, what stage they are,
32:37going back to the fact that some stage
32:40threes act even better than some stage twos.
32:43Also the risk of toxicities as
32:46well immune therapies can often
32:48times lead to permanent toxicities,
32:50endocrinopathies that require lifelong
32:53hormone replacement or steroid replacement
32:56for example versus reversible toxicities,
32:58more so in the case of oral targeted
33:02therapies with B raft neck inhibitors.
33:06We also have to factor in quality of life
33:08as well with some of these side effects.
33:11And then whether or not all of this is
33:14and what we're doing makes any impact
33:16in terms of how long people live,
33:18which is our ultimate endpoint.
33:21We have some interesting upcoming
33:23clinical trials here that many of
33:26you might have heard in the news.
33:28We will be opening the phase three
33:30portion of our personalized mRNA
33:32vaccine for Merck in combination with
33:35pembrolizumab that has been shown to
33:37reduce further the recurrence risk.
33:41In high risk melanomas.
33:44And so that it will be something that
33:45would be opening up in the next few months.
33:47And we also have additional
33:49trials of antitigit antibodies
33:51in the adjuvant setting as well.
33:53So really potentially interesting clinical
33:55trials coming down the pipeline. Next
34:01I'll take over from here and
34:04we'll talk about another case.
34:05This is a 73 year old male
34:08presented who with a left sided
34:10cervical lymphadenopathy.
34:11A CAT scan of the neck was ordered
34:14to further work this up and it
34:18showed 4 enlarged centrally necrotic
34:21lymphadenopathies lymph nodes.
34:23Biopsy of the left scalp lesion
34:26revealed a Melanoma.
34:29An ultrasound guided biopsy
34:30of the left cervical node was
34:33positive for metastatic Melanoma.
34:35He subsequently underwent white local
34:37excision of the left parietal scalp
34:39lesion and the patch revealed metanoma
34:41and cyto and scar with negative margins.
34:46Left neck lymph nodes were excised
34:48and three out of 10 are positive
34:52for metastatic Melanoma.
34:53Next line he subsequently presented
34:57to ER with generalized abdominal pain,
35:00nausea,
35:00vomiting and diarrhea for three days.
35:03The CT of the other men and
35:05pelvis show liver metastasis,
35:06peritoneal carcinomatosis and bowel
35:08obstruction with antisusception
35:10and mass of the transition point.
35:13He underwent surgery ilial bowel resuction
35:17of metastatic Melanoma and anastomosis.
35:20Subsequently he developed
35:22symptoms of dizziness.
35:24MRI of the brain performed
35:27showed 49 to predatorial and
35:2914 in predatorial lesions.
35:34Next time I'll
35:37turn it to my colleague.
35:39Thank you, Flora. So when we
35:42talk about metastatic Melanoma,
35:44people generally feel, oh, it's stage 4,
35:47it's a terrible prognosis.
35:48We're actually within the last 20 years,
35:51we've had a lot of new targeted
35:54therapies and immune therapy
35:56combinations that have sort of changed
35:59the paradigm for how we think about.
36:01Stage 4 disease, historically 5
36:04year survival has been very dismal,
36:07but that is ongoing in terms of
36:10improvements within the last few decades.
36:13So in the middle here we have sort of
36:16an outline of the recent drug approvals
36:20that include now immune therapy,
36:23combinations of immune therapy in the
36:26systemic setting for metastatic disease.
36:29Which is which are all labeled
36:31above the the timeline bar there.
36:33And to even add on to this and give
36:36give a quick update within the last
36:39year two additional new treatments
36:42were are also approved as well.
36:44So when we talk about metastatic
36:47Melanoma combinations of the
36:49Lumumab and Volumeab are now having
36:52demonstrated objective responses
36:54rate response rates of around 58%.
36:57Which is astounding.
36:58So this means patients that
37:00respond have stable disease or
37:03even complete responses as well.
37:05There are multiple treatment options
37:07that we can try for these individuals,
37:09some of them more tailored to certain
37:12subtypes of Melanoma such as UVL melanomas,
37:16but overall,
37:17really kind of changing the paradigm here.
37:21When we talk about immune therapy,
37:23which is intravenous versus targeted therapy,
37:26which is oral,
37:28really the individuals that can only
37:30benefit from the targeted therapies are
37:32the ones with activating the graph mutations.
37:35And so that's only a smaller
37:37subset of individuals.
37:39And when we talk about sort of what
37:41is the correct sequence of therapies,
37:44this is has been recently addressed
37:46in the DREAM SEEK trial and we now
37:49know that frontline immune therapy
37:50is superior to targeted therapy in
37:53terms of multiple factors including
37:55overall survival,
37:56progression free survival and the
37:58duration of response to treatment
38:00as well
38:03next so. Immune therapy can
38:06cause multiple different types
38:08of immune related toxicities,
38:10which my colleague Dr.
38:11Kluger will detail for us now.
38:15Thank you Doctor Tran.
38:16So everything comes with
38:18the price unfortunately.
38:19So these immune therapies are wonderful
38:21in that not only do they induce response,
38:23but these response can be these responses
38:25can be durable and last for many, many years.
38:28We have many patients who are
38:30alive and well over a decade after
38:33stopping the immunotherapy.
38:34The other advantage to the immuno?
38:35Therapies that you can treat for a
38:37certain period of time and then stop,
38:38they're not on continuous therapy,
38:41but the the price to pay is the
38:43immune related adverse events.
38:45So if you think about the mechanism
38:47by which these drugs work,
38:48it's not really specifically
38:50targeting the cancer cells.
38:51So we stimulate the immune
38:53system in a nonspecific way,
38:54but we also have T cells that
38:57recognize our normal organs
38:59that are that are quiescent.
39:02By various mechanisms and they are,
39:04they remain that way during our
39:06our lifetime but they they live
39:08there as resident memory cells.
39:10So these these cells actually live
39:12in almost all organs in our body.
39:15And when we inhibit the breaks on
39:16these cells with immunotherapies
39:18that we administer,
39:19you then can get inflammation
39:21in almost any organ in the body.
39:23The common ones are the hormonal
39:27side effects,
39:29colitis and respiratory problems.
39:31Now some of them are quite
39:34reversible with very responsive to
39:36immune to to immune suppression,
39:38specifically steroids and sometimes they
39:39resolve quite quickly when we give steroids,
39:42others may remain permanent.
39:43So for reasons that we still don't
39:46quite understand the endocrine
39:48toxicities are never reversible.
39:49Diabetes or type one diabetes
39:51can be fulminant,
39:52it's quite rare,
39:53less than 1% but very difficult to control
39:56and certainly a life altering event.
39:59Hyperpituitism occurs in around 15%,
40:02that's one 5% of our patients.
40:05And if you think about a patient who
40:06might be cured with surgery alone,
40:08receiving immunotherapy in the adjuvant
40:10setting causing pituitary insufficiency
40:13as a lifelong toxicity certainly
40:15can affect them for decades to come.
40:18And these patients are at risk when they
40:20when they get sepsis or undergo surgery.
40:22So if you have any of those in your practice,
40:24please keep in mind that they need stress,
40:27those steroids if they ever get sick.
40:30Sometimes the neurotoxicities and the
40:32cardiac toxicities are also irreversible.
40:35The death rate from the immunotherapy
40:37is quite a bit less than 1%,
40:39but sadly we've all had a death
40:41and it's something that does occur
40:43regardless of how careful we are.
40:45The other problem that we have is
40:47that we have no means by which we
40:49can predict who's going to develop
40:51the toxicities and who won't.
40:52There are a number of immune
40:55suppression approaches that we use.
40:57They listed over here on the
40:59right primarily steroids,
41:01but I think this field is undergoing
41:03rapid evolution and I believe that
41:05in the next 5 to 10 years we'll be
41:08using an array of different immune
41:09suppressants that might be more specific.
41:13To the the resident memory cells
41:16rather than the anti
41:17cancer immune cells.
41:19So more to come on that as we go as
41:22we proceed into the next decade.
41:25Next slide please.
41:25So the next question is what do
41:27we do about patients who have
41:29underlying autoimmune disorders.
41:30So I think all primary care folks
41:32have many patients in their practice
41:35who carry a diagnosis of RA,
41:36Polymyalgia, Rheumatica and the like.
41:39And I think that sometimes
41:40these diagnosis were made many,
41:42many years ago,
41:44disease can possibly burn out with time.
41:47But we have been successful in treating
41:50some of these patients with immune therapy.
41:53It's it's challenging often
41:55we need to pay extra,
41:58extra attention to these folks but
42:00certainly if they have an underlying
42:03autoimmunity that's not life threatening,
42:06the immunotherapy can be administered.
42:09Quite safely.
42:09I do specifically want to draw your
42:11attention to inflammatory bowel
42:13disease because it's increasing
42:14in incidence and that is actually
42:16particularly challenging for us because
42:18patients actually can die of bowel
42:20perforation if we're not careful.
42:22It doesn't mean we can't do it.
42:24We can give therapies that are active
42:26specifically in the bowel such as
42:28veto lizumab and sometimes we are
42:30very successful with that and can
42:32induce a long term cancer remission.
42:35Next slide please. Thank you.
42:37So lastly, but certainly not least,
42:42brain metastases in Melanoma
42:43is a big problem for us.
42:45Approximately half of our patients
42:47who have metastatic disease develop
42:50brain metastases at some point in the
42:52course of their illness and they can
42:54sometimes present with brain metastases
42:56as the first site of metastatic disease.
42:58So they'll present with.
43:00Headaches, neurologic problems,
43:01et cetera.
43:02The tip off is that the headache
43:04is worse when they lie down.
43:06It gets better over the course of the day.
43:09The headaches can be
43:10severe as the tumor grows.
43:12One can have a Mass Effect
43:15midline shift and the
43:16one thing that Melanoma
43:18brain metastases.
43:20Unfortunately, do is is is hemorrhage.
43:24So other than many other tumor types,
43:27these are more prone to hemorrhage.
43:28And there's a lot of Peri lesional
43:31edema around these lesions,
43:32possibly more than in other tumor types.
43:34And it's the edema itself that can
43:36actually cause problems and actually
43:39Doctor Tran has done a lot of.
43:41Research on this topic in particular,
43:44there are better treatments available.
43:46We've got effective systemic
43:48therapies for brain metastases.
43:50We believe that immune therapies,
43:52when they work in the body,
43:53they're going to work in the brain as well.
43:55But sometimes we have complications such as
43:57the edema and resultant symptoms from that.
44:00These lesions can be Gamma
44:02Knife with radiation therapy,
44:04or they can simply be treated
44:07with systemic therapy.
44:08We tailor individual treatment plans
44:10to all of these patients because
44:11brain metastases are not alike.
44:13Some patients may have one big one,
44:15while others, well,
44:16they can have many small ones.
44:17Some have hemorrhagic lesions,
44:19some have lesions that cause a lot of edema.
44:24So this arena as well is an area
44:26of very active research at Yale.
44:31I'm going to turn it back to
44:32Doctor Tran to talk about the
44:35conclusions and the major takeaways.
44:39So I think Doctor Kluwe,
44:41you highlighted on a lot of these
44:44and very important side effects
44:46that it would be important for our
44:49primary care colleagues to know about.
44:51We are typically very aggressive about
44:53treating these individuals metastatic
44:55Melanoma with immune therapies.
44:57Sometimes we do seem like we
44:59push them to be able to receive.
45:01Their treatments only because we
45:03know based on experience that if if
45:06they're able to attain a response
45:09with immunotherapies that response
45:10can be profound and longlasting.
45:13But unfortunately what happens during
45:15the course of the this treatment
45:17is a lot of lifelong toxicities can
45:19develop which we need our primary
45:21care colleagues to be aware of
45:23and to have a low threshold about
45:26helping us to Co manage them.
45:28So things like adrenal insufficiency
45:30in patients who are presenting
45:32with a Uri symptoms,
45:34they need to be stressed,
45:35dosed and sometimes we can avert
45:37hospital admissions if the patient and
45:39the primary care physician are aware
45:42that tunes to this potential side
45:44effect also and as Doctor Kluber alluded to,
45:48you know diabetes.
45:49These type one diabetes that can
45:51develop on immune therapy are very life
45:55changing and require multidisciplinary
45:57care with endocrinology and primary
45:59care to help manage thyroiditis is
46:01sometimes one of the side effects that
46:04we can see that perceives hypothyroidism
46:06in these patients depending on how
46:09frequently we check the the TSH levels.
46:11I think one of the also the important.
46:14Facts that as a primary care physician,
46:18if you have a patient that you know
46:19who is on immune therapy presenting
46:22with extreme fatigue,
46:23one check for the endocrine potential
46:25side effects but also make sure that
46:28they aren't having myocarditis too.
46:30If you know or you suspect our toxicity,
46:34please let us know.
46:35Reach out to us, we're happy to be involved.
46:38We don't expect primary care to
46:41manage the toxicities acutely,
46:42but just letting us know how helps
46:46us to determine what treatment,
46:48you know,
46:49is indicated for the individual
46:51toxicities at hand.
46:52And a lot of the times even though
46:55patients may develop a toxicity,
46:56it's actually might be a good sign
46:59that maybe their immune system is
47:01being activated and potentially will
47:03produce the anti Melanoma response.
47:06So we've seen correlations between
47:09very severe toxicity toxicities and
47:11very good responses in our patients.
47:14So in terms of treatment assessments,
47:16so going back to the case in hand,
47:19this gentleman who Doctor Lena and
47:21I treated with metastatic Melanoma.
47:23He was treated with a combination
47:26of ipilumab and uvalumab.
47:28And after the first four cycles,
47:30so looking at his scans,
47:32pretreatment on the left and then
47:34on treatment after four cycles,
47:37there is a dramatic improvement
47:39in disease tumor burden both in
47:41the brain and in the body.
47:43Typically with immune therapies
47:45these responses are concordant
47:47because these are known to be
47:50brain active treatments as well.
47:52Early on though,
47:53if you do happen to come across a
47:55scan for a patient on immune therapy,
47:57just be wary that pseudoprogression
48:00can exist in these patients on early
48:03scans whereby the tumors may look
48:05bigger on imaging, but actually not
48:08be a full real tumor progression,
48:11but actually just radiographing
48:13enlargement from the infiltration
48:15of activated immune cells.
48:17Clinically, we can sometimes determine
48:19pseudo progression because the
48:21patient otherwise is doing well,
48:23they don't have any symptoms and if the
48:27degree of enhancement is not significant,
48:30then sometimes we will push these
48:33patients continue treatment and
48:34then confirm with restaging later
48:36on whether or not they had pseudo
48:40progression or true progression.
48:42So patients are able to eventually.
48:46In a subset of folks obtain
48:48complete responses,
48:49basically almost a curative response
48:52to their systemic immune therapy
48:54and sometimes patients are able to
48:56stop and have ongoing responses
49:00next. So just to close out the
49:04take away points from today's
49:05presentation is you know
49:07early detection is critical.
49:09And that's where you know all
49:11hands on deck are appreciated,
49:13primary care's involvement and
49:15doing ongoing surveillance,
49:17looking at the scar,
49:18checking the patient's lymph nodes,
49:20assessing for any unusual atypical symptoms.
49:24Because early detection is always important
49:26in terms of improving ultimate outcomes,
49:29and everyone plays a role
49:31in the surveillance.
49:32It's a truly multidisciplinary,
49:36multiexpertise kind of approach here.
49:40So aggressive upfront Melanoma
49:42management and treatment,
49:44as we always said,
49:45leads to improve outcomes not only
49:47for the patient but also to help
49:49minimize potential toxicities as well.
49:53Fortunately, we've lucky enough to
49:55work in a field where therapeutics
49:57are always improving and we've
49:59been at the forefront of helping to
50:01push that boundary forward with the
50:03ongoing clinical trials here at Yale.
50:06And the number of patients that are
50:08living with a history of Melanoma is ever
50:11growing and we owe that and thanks to.
50:14The drugs but also the close corroboration
50:17that we have between or specialty
50:19with in Melanoma but also with
50:22ongoing primary care physicians too.
50:26That was absolutely terrific.
50:30Thank you for all of that.
50:34Those who are watching please
50:37submit questions using the Q&amp;A
50:40because we we do have some time.
50:43Left over and you know I just
50:45have to say as a mature primary
50:48care physician that the change in
50:51prognosis for advanced Melanoma
50:53is one of the most miraculous
50:56things I've witnessed clinically.
50:57So it is amazing and it it's just
51:01nice to hear that whole kind of
51:04evolution outlined although not
51:05without a price as we as we've heard.
51:10As we wait for some questions to come
51:11in and and those who are watching,
51:13please do submit questions.
51:16Flora, do you have additional
51:18questions for our Smilo panelists?
51:21So sure, a basic question.
51:24When we are dealing with a patient in
51:26the office who we suspected toxicity,
51:28what's the shortcut?
51:30What's the the easiest way and
51:33fastest way as well most effective
51:35to get in touch with with the
51:37team caring for this patient.
51:40So we have one phone number that's
51:45to 203-200-6622.
51:46We make sure that all patients who start
51:49immunotherapy put that on speed dial.
51:52Someone answers that phone
51:5424/7 during work hours.
51:56They can send a message in my chart.
51:58It goes straight to our nursing pool,
52:00but depending on the urgency,
52:02they may decide to call.
52:05And whether they seen in Guildford
52:06or in New Haven, they the phone
52:08calls for urgent issues such as
52:10that would come into New Haven.
52:14Thank you.
52:17And I'll just add on to that.
52:19When we have somebody, you know,
52:21with a skin lesion in primary care,
52:23we have ones that are like we
52:25can't really tell you it's normal.
52:27And then we have ones that like look
52:29like they might be a problem and then
52:30they have ones that that scream at us.
52:32This person absolutely needs this remove.
52:34Right away and delaying care is not good.
52:38You know within the kind of Yale system,
52:41what are some of the most efficient ways
52:43that we can kind of help to navigate
52:45and and refer those type of people.
52:49Sure. I can take this one.
52:50Well, I think you know we have many
52:53dermatology services outpatient
52:55all all throughout New Haven
52:57and Brantford and Middlebury.
52:59I think putting in an urgent referral.
53:01I think what what often helps is calling
53:03the office also just to leave a message.
53:05We're really worried about this one.
53:07A lot of primary care doctors will
53:09send me an epic and basket message.
53:11Can you please get this patient
53:12in soon with you or a colleague,
53:13We're really worried about this one.
53:15I think that sort of triage is is helpful.
53:17We also have telemedicine to
53:19look for urgent lesions,
53:21but I'm I'm more of a proponent of seeing
53:24the the patient in in person to examine it.
53:27So we can use a dermatoscope and biopsy
53:32and then doctors are power
53:35actually alerted me as to these.
53:37Little things I I use them in the garden.
53:39When I see a weed or something that I
53:41think might be a weed or maybe the plant
53:43I planted last year and forgot about,
53:45I I use this identify thing and it
53:47tells me exactly what the plant is.
53:50Is there a software that can help us?
53:52You know, there's a lot of new
53:55technology and iPhone apps.
53:56I think a lot of these aren't
53:59really validated and I don't think
54:01anything beats right now seeing a
54:04dermatologist for any evaluation,
54:06maybe 1. Technology,
54:09we'll get there.
54:11So immunotherapy first, technology second.
54:14So we do have a couple of
54:16questions that have come in.
54:17So Shepherd, Stone has or Stone Shepherd
54:21I'm not sure has asked when should a
54:24PCP perform biopsy and when they when
54:26should they refer to a dermatologist.
54:28Now not all of our Pcp's do biopsy,
54:30but if it's within the skill set what,
54:33what do you think
54:36so? I'm aware that you know,
54:38primary care physicians,
54:39certainly you know some do biopsy.
54:41I think if you're going to
54:43biopsy a pigmented lesion,
54:44it's really important to to be sure
54:47that that you sample the lesion
54:49in its entirety because if you
54:51only sample a small portion of it,
54:54you might miss the Melanoma.
54:56Further, if it is a Melanoma
54:58but you transect it,
54:59you really won't have an accurate
55:02stage of the true Breslow depth.
55:05I would say if it's something that
55:07you've been trained in and and
55:08you're capable of doing do so.
55:10But in general,
55:11you know this is kind of what bread
55:13and butter dermatology is and we're
55:14very happy to see those patients.
55:18And another question from Dr.
55:21Allard, what are your Melanoma
55:24screening recommendations by age
55:26despite the USPTF not recommending
55:29annual screening? Another
55:31really good question.
55:31I think a lot of it comes to those
55:34risk factors that I alluded to.
55:36I don't think somebody who has few
55:39nevi darker skin, no personal or
55:41family history needs to to be screened.
55:44If you see someone even at a young
55:47age who has a strong family history,
55:50has a lot of nevi and in
55:53particular has a lesion of concern,
55:55I think that's the key.
55:56If there's a lesion of concern,
55:58that's an automatic should be evaluated.
56:00Those screening guidelines don't
56:02apply to a concerning lesion.
56:04I think if it's a young child
56:06who maybe has a parent or grant,
56:08you know, with Melanoma but
56:09certainly is a primary care doctor,
56:11you don't see anything concerning.
56:13I don't think it's urgent to
56:15have that that child screened
56:21well. That's the end of our questions that
56:25have come in and also the end of our hour.
56:29So again, I, you know,
56:30each of you spent time to prepare for this.
56:33It was just so well delivered and full
56:36of information that I think is really,
56:38really helpful. So these connections,
56:41these moments are valuable
56:44and and I thank you for that.
56:45And I thank you to those who took time
56:47to listen despite a like very bad,
56:50awful, horrible IT day here at the
56:53health system because we know it
56:56took special effort to get here.
56:58And encourage your friends to watch the
57:00recording, which we'll also send out.
57:01Good. Thank you all.