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Oral Board Review: Breast and Melanoma Mock Orals (Podcast)
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Oral Board Review: Breast and Melanoma Mock Orals (Podcast)
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>> Behind the Knife, the surgery podcast where we take a behind the scenes, intimate look at surgery from leaders in the field. [ Music ] >> Okay, welcome back to another episode of Behind the Knife. This week we are doing some more mock oral scenarios, residents around the country get pretty anxious around mock orals and oral boards time, and keep requesting that we do more scenarios, and one topic that is always nerve wracking is breast and melanoma.
And so luckily we have the Chief of Surgical Oncology at the University of Michigan, Dr. Sable, here taking time out of his Sunday evening to join us on Behind the Knife, and do some mock oral scenarios. Welcome Dr. Sable, and thank you again for joining us. >> Thanks for having me again. >> And then we have a very brave Resident, Bahag Nickoleon [phonetic spelling] from The University of Michigan, who has volunteered, and also took time out of his Sunday night, so welcome Bahag, and thank you for joining us.
>> Thank you for having me. >> All right, and we'll let Dr. Sable take it away. >> All right. We'll get started with an easy one, just to sort of ease you into it. A 44-year-old male presents to your office because he has an atypical mole on his left flank. He is pretty sure it has been there for a while, but his wife thinks it has changed. She thinks it has gotten a little bit larger, and looks a little bit more irregular to her. So he is here to see you for further evaluation.
>> All right, well with any patient that presents with a skin lesion, I would start with performing a very thorough history and physical. I would start with my history, specifically asking the patient and his wife about how the-- when they first noticed the lesion, and what sort of changes in appearance, size, or sort of features that they've noticed, and whether or not they've had any bleeding or ulceration associated with it. And then following just a quick history there, I would also ask the patient about their past medical history, focusing specifically on personal history of any prior melanomas.
Multiple evaluating and determining if they have any other atypical moles or dysplastic nevi, determining if they have a family history of melanoma or any other genetic mutations or inherited problems with malignancies. And then evaluate for environmental risk factors, such as exposure to excessive sun or tanning beds. >> All right. So basically there has been no bleeding, no ulceration, the patient thinks that he had a grandfather who had some type of skin cancer, as in, you know, older individual.
But he doesn't really know the details of it, and otherwise there's nothing that really jumps out about the family history and sun exposure, yeah, when he was younger. He got some burns on vacations, but nothing that he thinks were particularly excessive. >> Okay. Then move on to like a review of systems, specifically evaluating for any evidence of possible metastatic disease. Any changes in or neurological symptoms that they may have noticed. Any cardiopulmonary issues, any abdominal pain, then any fevers, chills or recent weight loss.
>> Okay, and he is asymptomatic. He has really been feeling great lately. >> Okay. Following that, I would move on to a physical exam. I would do a head to toe examination, but then pay close attention to the lesion itself, evaluating for the ABCs of melanoma, asymmetry, irregular borders, color variation or the diameter, and then also I would do a very thorough examination of his lymph node stations, cervical, supra and infraclavicular areas, axillary and inguinal regions.
>> And the lesion itself, it's about 3, 4 millimeters. Definitely has irregular margins, and almost looks like there is more than one color to it. But there is no clear ulceration and all of his lymph node basins are negative. There is no palpable adenopathy. >> Okay. I would also evaluate the rest of his skin, and make sure that I don't find any other lesions that are concerning, evaluating his skin, scalp, and nail beds. Anything on that?
>> That is all negative as well. >> Okay. At this point, we have a patient who is presenting with an atypical lesion. It's relatively small. I would be comfortable performing an excisional biopsy or punch biopsy in the office to then send off for evaluation by pathology. >> And you do so, and the biopsy returns as a 3.1 millimeter nodular melanoma, non-ulcerated, mitotic rate of 3.
>> Okay. So a 3.1 millimeter lesion, nodular, so for this particular patient with an intermediate lesion, I would talk to the patient specifically, letting him know that I would want to perform a wide local excision. I would want to have 2 cm margins, and I would also want to perform a sentinel lymph node biopsy. >> All right. So you take him to the operating room for a wide excision and a sentinel node biopsy.
Can you just briefly describe your sentinel node procedure? >> All right, so in advance of the procedure I would have the patient have sulfur colloid injection around the site to then evaluate for where the sentinel lymph node drainage occurs, as well as intraoperatively, following induction, I would plan to administer methylene blue around the site of the lesion to have a sort of another way of detecting sentinel nodes.
I'd follow up with that then evaluate for where the tracer went, and plan to perform a biopsy of the area that it drained to. >> So in this case, his lymphoscintigraphy shows drainage, simply to the left axilla. You perform a wide excision, sentinel node biopsy, you identify two sentinel nodes, hot, blue, the pathology comes back showing there was no residual melanoma on the flank, there were two axillary sentinel nodes, one of which had melanoma.
It was about a 1.5 millimeter focus in the node. >> Okay so for this patient a 1.5 millimeter focus in the node, I would recommend that, given these findings, we should perform a completion lymphadenectomy of the axilla. I would talk to them that there is some data to support observation, but I don't believe that he would meet criteria because of the penetration was greater than 1 millimeter.
>> Okay. So he undergoes a complete axillary lymph node dissection. There were 20 nodes, all of which were negative. >> Okay. So at this point, we have no other evidence of disease, so at this point, I would begin the process of sort of postoperative care with this patient, specifically wanting to have the follow up with me every six months for five years, and then annually.
>> Is there anything else you would want to talk to him about? >> Specifically I would want to talk to them about the role of, well discussion with the Multidisciplinary Tumor Board, and a decision whether or not the patient would be a candidate for observation versus treatment with Interferon or ipilimumab. >> Okay. Excellent. Let's back up two seconds, and say you recommend an axillary lymph node dissection, and he says he was reading an article recently that sort of suggests that's not really necessary in every patient, and he'd really like to avoid an axillary lymph node dissection if possible.
What would you counsel him about? What are his other options? >> So the other option, he may be referring to the MSLT-2 trial, which evaluated whether or not observation would be appropriate. In certain patients, you could perform observation which would entail ultrasounds done every four months for the first two years, and then every six months following that for another three years.
With that sort of mechanism, you would be evaluating to see if the patient develops positive nodes in their lymph node station. Positive nodes would be described as anything with a length to [inaudible] ratio greater than 2, already concerning findings, for that matter, and at that point, you would then perform a lymph node dissection. >> Okay, so let's say he opts for no dissection. I'm sorry, he opts to not undergo the lymph node dissection, he opts to simply have the follow up ultrasounds.
And he's back at his eight-month follow up appointment, and you do your physical examination, you don't find anything on exam. He feels great, no symptoms. But his ultrasound does show an abnormal lymph node. What would you do at this point? >> So abnormal lymph node, at this point I would recommend that we proceed with an axillary lymph node dissection to remove it, because there is a high likelihood that he now has disease affecting that site.
>> All right, fair enough. Okay. So, first of all, excellent job. The workup was very thorough in the beginning for the patient with the atypical skin lesion. I think you covered everything very well. You had a very good history. You remembered to do a thorough review of systems. I think it is always important in any cancer patient to really focus on a thorough review of systems for two reasons. One, because if there are symptoms that might be suggestive of metastatic disease, it's going to increase your suspicion of whatever abnormality they're presenting with, whether it's a breast mass, or abnormal imaging finding, or in this case an atypical skin lesion, but also that review of systems is going to change how you potentially stage the patient in the future and could even affect some of your surgical choices.
So I thought you did a really good exam. I like that you mentioned the full skin examination. Every patient with a melanoma, with a skin cancer, you know, there is a risk that they might have another skin lesion somewhere, whether it's an atypia, or a melanoma in situ, or another invasive melanoma. So every patient needs a really thorough skin examination, either you need to do that or the patient needs to see a dermatologist as well. You characterize their sun exposure.
You asked a lot of questions. To be perfectly honest, we talk about these things. Sometimes it's a little bit academic. We have a changing skin lesion, I'm not really sure what on history is going to change me, or change that course in terms of heading toward a biopsy. Any time somebody says listen, this mole was here for a long time, then it changed, you know, I'm going to biopsy that. And that really should, you know, should be the case. And you did a punch biopsy, not a shave.
That's a classic error. If you really suspect melanoma, it should be a punch biopsy or an excisional biopsy, or even a saucerization. Something that gets you down to that subcutaneous tissue so you really get an accurate representation of the depth. Your surgical management was dead on. This was a little bit of an easier one. Two centimeter margins for a melanoma over 2 millimeters, and a sentinel node biopsy clearly indicated in this case.
Your sentinel node technique, you used the combination lymphoscintigraphy, along with methylene blue dye. Not everybody does. Not everybody uses the blue dye. I find it personally helpful in terms of doing the case, so I advocate for it. And then, when the node came back positive, you sort of opted for a lymph node dissection. Why, in this patient, did you think that a lymph node dissection was really indicated? >> So, I recently read that MSLT-2 trial, and from what I remembered, the patients that were included in that trial had, you described the depths of penetration in the lymph node as 1.5 millimeters, and I thought that it was, the patients were less than 1 millimeter.
Is that correct, or am I just thinking that data up? >> So, well, no, no. No, it's not depth of penetration, it's just the size or the tumor burden within the node was about-- I gave you 1.5 millimeters. So you are correct that it wasn't a criteria for the study. So, for example, you didn't have to have a specific tumor burden within the node in order to then be randomized between surgery and no surgery. >> Mm-hmm. >> It turns out that when you look at the patients that were in the trial, the-- I think the median tumor burden or size of disease within the node was about a millimeter.
So this patient is not actually that far off from it. >> Okay. >> There are concerns about MSLT-2, in terms of was there a selection bias? Did we sort of lean toward patients with a little bit more of what we'd say is a minimal disease burden within the node, and then can you apply these results to patients that might have a higher tumor burden within the sentinel node? The reality is I don't think anybody knows the answer to that question right now. The authors tried to look at that.
It wasn't possible. There didn't seem to be a trend toward any sort of benefit as the tumor burden in the node got higher, so this is a confusing area right now. It really is. I think many of us are struggling with sort of how do we now apply the results of MSLT-2 to the population that we're seeing? I think for the most part we believe that many patients can now avoid the node dissection.
I think there are still some concerns that people have. The follow up was only about-- the median follow up was about five years, but the statistics were based on a three-year follow up. There are some people that are concerned that with longer follow up you might start to see some benefit, or at least in some populations, and again, there is the possibility of that selection bias. I would say that you're very safe in an oral board situation saying you would do the dissection. I don't think anybody would say that's wrong.
Personally, I would sort of say this is a patient who has a choice. And really I try to have a very balanced discussion with them about the pros and cons, about the benefits of regional control versus overall survival, and obviously the risks and benefits of the node dissection and the possible complications. And again, a lot of that is dependent upon the basin that we're talking about. So, for example, a neck dissection versus an axillary dissection versus a groin dissection.
They have different morbidities. And then when you take into account patient factors, and they also have different impacts in terms of a regional recurrence. You know, the morbidity of a regional recurrence in the neck might be more significant than in the axilla. And that all has to be taken into account. And so again, I think you're safe in either direction in terms of an oral board situation. In terms of recommending dissection versus no dissection. It's something we're all struggling with right now, and that's why I thought it would be a good topic to talk about in this scenario.
If you don't do the dissection, wow, you have that exactly right in terms of the ultrasound surveillance has to be a critical component, if you're not going to do the dissection. And I think that's another important thing for patients to remember if we're not doing the surgery. They have to commit to a relatively frequent follow up schedule. Although we really see them back at a similar schedule for their routine physical exams as well. And then, the question is really, what to do if there is an abnormal node.
Now, I have to say you shocked me that you really knew the definitions of what an abnormal node is on ultrasound, so kudos to you. I don't think I even read the study in as much depth [laughter], but it [laughter], if the patient does come back with an abnormal node on ultrasound, I think it's really important to understand that an abnormal node, even if it meets those criteria, doesn't necessarily mean that it's cancer. So I think the one place you deviated a little bit is you saw an abnormal node on the ultrasound, and you said, okay, now it's time to go back to the ALND.
I would actually have done a few things first. I would have done an ultrasound-guided FNA, and confirmed that it's melanoma. Because sometimes it's not. Sometimes it's reactive. There can be other reasons why a node looks abnormal. And the second thing is, I would do staging in this situation before I would go back for the axillary node dissection, and rule out distant disease. Because obviously if I now get a CT scan on this patient, and they not only have a recurrence in their nodal basin, but also lung metastases, I don't think my next step would be to do an ALND, I would be thinking about systemic therapy at that point.
>> Okay yeah. >> Or at least biopsy the distant disease, confirming that they actually have stage four disease. >> Dr. Sable, have you had a chance to use MSLT-2 to observe a patient since the data came out this summer? >> So, I will say, I guess for full disclosure, I'm a co-investigator on MSLT-2, so I accrued a number of patients through this study [laughter] as well and there was a time where I could have probably recited the ultrasound criteria. And yes, I have many patients right now that I have this discussion with, and we now have them on an ultrasound follow up schedule.
So yeah, we are actually applying it. There's a lot of patients where the sentinel node is positive, but it's relatively small tumor burden. I will say, just like we talked about, I struggle with the younger patient, with the patient with slightly more tumor burden, but I have to tell them the results of the trial. I have to balance discussion, and I have in those situations some patients that opt for surgery and some patients where I've probably leaned that conversation a little bit more toward the dissection, but again, this is based on-- I can't say it's based on hard science.
It is based on a little bit of gut feeling. >> Right. >> That was a good discussion. Should we go on to another question? >> Absolutely. >> Did I use up all my time for the podcast in one question? >> No, you have as much time, we're learning-- you also have a great radio voice, also so-- >> [Laughs] All right, we'll switch out of melanoma for a second, and we'll talk about another case.
You have a 33-year-old female who comes to your office, and she has a complaint of a left breast mass. Now, she has never noticed this before. It's in the upper, outer quadrant of the left breast. It's nontender. It is mobile. She's not really sure if it's changing or not, because her breasts are changing, because she's actually 14 weeks pregnant. And she came to you for evaluation of this breast mass.
So what would you like to do? >> Okay, so for any patient that comes in with a breast lesion I would start with a thorough history and physical. Initially I would evaluate the patient to determine if there's any symptoms associated with the affected breast, specifically asking for skin changes, dimpling, nipple discharge, and take a thorough history, which would include previous history of breast cancer, mammogram history, as well as previous breast biopsies.
I would ask her about her family and personal history of breast or any other gynecological cancers, and then do like a, so for a pregnant patient, I would do a pregnancy-specific evaluation which would include when she was pregnant, determine the anticipated date of delivery. >> Okay-- >> I think that's where I'd start, yeah. >> She's 14 weeks pregnant, and everything is going along swimmingly with her pregnancy. On her history and physical examination it is-- well, I don't think you've gone to physical, but on her history, this was an incidental finding.
It really isn't causing her any symptoms whatsoever. Her review of systems is negative. She is otherwise in good health. She has some symptoms related to her pregnancy, but nothing out of the ordinary or unexpected. Her family history, she has an aunt that had a gynecologic cancer, but she doesn't know what kind it was, and she was in her 40s when she had it. Other than that, she's not really sure about any other cancers in her family history. >> Okay. I would move on to a physical exam. I would do a full physical exam, and then focus on a bilateral breast examination, looking for any asymmetry, dimpling, or evidence of skin changes.
I would evaluate for nipple discharge, then do a focused examination of her lymph node stations. >> So in the upper, outer quadrant of the left breast, there is a smooth, round, mobile mass. It is not tender. You would estimate it to be about a centimeter and a half in size, and she has no regional adenopathy on exam. The remainder of the breast examination is completely within normal limits. >> Okay. So at this point, we have a pregnant woman at the very beginning of her second trimester, who is presenting with a breast mass.
I would plan to refer her for imaging, specifically an ultrasound, to evaluate the extent of disease, and for a possible biopsy. My preference would be core needle biopsy. >> Okay. So you get an ultrasound, the ultrasound shows a 1.5 centimeter round solid mass, no cystic component. And there's nothing else on ultrasound that is abnormal. And then you said you wanted to do a core biopsy.
>> Yeah. >> Okay. A core biopsy, unfortunately demonstrates she has an invasive ductal carcinoma. It is ERPR positive. It is HER2 negative. Grade 2. >> Okay. All right. At this point, I would want to move forward with a staging workup for this patient. It seems to be about a T1, T2 lesion, so for her, I would recommend chest x-ray, we could shield the baby, and then get just a full set of laboratories as well.
I don't think she needs any other workup for metastases, but I would consider possible ultrasound of the liver, or MR of the brain, if she had any symptoms. >> Okay. You just get the chest x-ray and the labs, and those are normal. >> Okay. So for this patient, she has invasive cancer, she is ERPR positive, she is in her second trimester, breast conservation that is something that is a little controversial.
For her, I would talk it over with her, and I think most likely I would recommend a mastectomy. >> Okay. So you're booking her for the operating room, you're scheduling her for a left mastectomy? >> With...so she is right at the beginning of her second trimester, so yeah, I would say mastectomy with axillary lymph node dissection.
>> Okay, so modified radical mastectomy. >> Yes. Yes, I'm sorry. >> All right. The-- okay, you take her to the operating room for a modified radical mastectomy. It shows a 1.5 centimeter tumor, negative margins, and the lymph nodes show one of 15 nodes positive for breast cancer. >> Okay. All right. So at this point, for this patient, with her current stage, I would say that chemo can be given in the adjuvant setting, I would say for her with regard to her endocrine therapy, I would wait until post-partum.
She was HER2 negative, so she wouldn't qualify for Herceptin therapy. >> Okay. Let's switch it up a little bit. Let's go back a second. Let's go back to the biopsy, but now, the biopsy comes back not ERPR positive, HER2 negative, but rather comes back as a triple negative, ERPR negative, HER2 negative. Is there anything you would do differently in that case? Should there be anything that you do differently in that case?
>> You could consider neoadjuvant chemo, in that particular case, but I would most likely just recommend, just given how early it is in the pregnancy, I would recommend the mastectomy with axillary lymph node dissection, just because I feel like breast conservation therapy would be challenging this early in the pregnancy. >> Okay, fair enough. So again, a very good job, very thorough. I think you managed it quite well.
You didn't fall into the trap of having a pregnant woman present with a benign-appearing mass and not biopsy it. I don't think anybody would make that mistake on the orals, because I don't think anybody walks through the orals thinking any breast mass is going to come back as a cyst or fibroadenoma. But sadly, we actually see that error made clinically, where a lot of times you see a very smooth, mobile mass. It doesn't have a lot of worrisome characteristics, and people just sort of assume that it's a galactocele, or a fibroadenoma, and don't do the biopsy, and sadly we see a delay in diagnosis of breast cancer in women who are pregnant.
So it's important not to make that mistake, and you did not make that mistake. In the workup, there are just two things I would comment on. The first is you made a comment that you would talk about their family history, any personal history of breast cancer, any history of ovarian cancer, and any family history of gynecologic cancers. To be perfectly honest, whenever we have a patient with cancer, including breast cancer, we want a thorough family history of all cancers.
It's a common comment that is made by residents. Not just on the oral examinations, but even just in the course of daily conversations where people say, well, I would want to know about the gynecologic cancers. There are several genetic syndromes, genetic predispositions for breast cancer that include cancers that are non-gynecologic. So we wall tend to think very commonly about BRCA1 and BRCA2, which of course you know is associated with a very high risk of breast and ovarian cancer.
But the reality is, BRCA1 is associated with an increase in the risk of prostate cancer. I'm not sure if we're considering prostate cancer a gynecologic cancer [laughter], but there are other syndromes as well. There are other mutations, there is the Li Fraumeni Syndrome, there's check mutations, there is P10, there are other syndromes that can be associated with other types of cancer, that are not necessarily gynecologic. So there's no real reason on the oral examination to even, you know, sort of box yourself in like that with phrases like gynecologic-- I would just take a very thorough family history.
I'd be particularly interested in breast and ovarian cancer. I'd want to know the age of the relatives, when they had cancer, in terms of breast cancer, bilateral cancer, and triple negative cancers are all risk that would increase your suspicion potentially of a BRCA mutation or another type of genetic predisposition. So just say family history and say what's important about a family history, but don't sort of box yourself into gynecologic cancers. It's a very common sort of error. The only other thing I would say about the workup, this is a situation where I would obtain a mammogram, as well as an ultrasound.
Now, I'm not saying it's definitely right or wrong, she's younger, and a lot of times will just use ultrasound, but in a patient where I may suspect cancer, I would want to get a mammogram as part of that workup and you can shield the fetus in a pregnant patient from mammography. So mammography is something that you can do during pregnancy. I certainly appreciate that you try to avoid it in the early workup, but I think once it comes back as cancer, particularly as we are discussing surgical options, I think it's going to be important at least at that point to go back and get the mammogram.
I would have trouble moving forward necessarily with discussing surgical options in a patient who hadn't had a mammogram, with a known cancer. And I'm assuming you didn't want to get the mammogram because she is pregnant. >> I thought about, I elected not to, just because I felt like she was at that point in her pregnancy where I wouldn't be comfortable doing anything but a modified radical, so I didn't feel like [coughing] the rest of the breast would make a difference in my management.
>> Right. Well, okay, but let's talk about that as well [laughs]. So, okay, so I would have gone to mammogram. I'm perfectly comfortable with not getting it right off the bat, and of course, in the real world, often this will come back as a fibroadenoma or something benign, but if it comes back as a cancer, and I hadn't gotten a mammogram, I would have gone back and one that. You've got the staging test, I don't typically do them in this situation. You got a chest x-ray, and yes, you can obtain a chest x-ray safely in a pregnant patient. Nothing wrong with that.
They're relatively low yield tests, and I don't do them as a matter of routine pregnant versus not pregnant. If this is a more advanced cancer, and I was interested in staging the patient, you're right, I can't do a CT scan, I can't do a bone scan, but liver ultrasound, brain MRI, those are all options that are available in that situation. In this case, I probably wouldn't do much about staging. The only thing I would have done, probably in addition to that is I would have this patient meet with a genetic counselor, and consider genetic testing.
So yes, the family history wasn't terribly impressive, although she did have one relative who had a gynecologic cancer at a younger age. But she is 33. With breast cancer, and so obviously a woman that age, we're going to refer for genetic counseling, and genetic testing. Even in the absence of a family history. So that would have been an indication for genetic testing. And that would have been important too, because this patient may be interested in bilateral mastectomies as a surgical option.
And so again, pregnant, not pregnant. It's always important, younger women, women with a strong family history, that we really think about genetic testing, genetic counseling. We never really just send patients for genetic testing, we always do it in concert with a counselor, because there's a lot of difficult issues related to it. You made the comment that you didn't want to do BCT because it was controversial. I would say it's more than controversial [laughs], it's contraindicated. We cannot use radiation in a pregnant patient.
We can shield them from a chest x-ray or mammogram, you cannot shield from the radiation, and so it's absolutely contraindicated. So here's a patient, they were ERPR positive, HER2 negative, and not really chemotherapy candidate at that point, so you're not going to give them that neoadjuvant chemotherapy. She needs surgery, and this is where it gets difficult because in a patient in the second trimester, she's not going to be able to undergo breast conservation, so she is a mastectomy patient. So you said that, you got that, and you ultimately came to it, I just-- again, sometimes on the orals, residents tend to throw out additional terms and phrases that might not be necessary.
And that's an example. You know, oh it's controversial-- no, it's contraindicated. But you did an MRM, and you didn't want to do a sentinel lymph node biopsy. How come? >> So sentinel lymph nodes, I wouldn't do it because one, you can't give methylene blue during pregnancy. And then sulfur colloid scan, there isn't much data, I believe, on them during pregnancy. And then finally, doesn't like lymphatic drainage change during pregnancy?
Like, and potentially can impact sentinel lymph node biopsy results? >> So I would say that there has been some conversation, especially early on in terms of the accuracy and the safety of sentinel lymph node biopsy in pregnancy. I think today most of us agree that it's perfectly safe and accurate to do sentinel lymph node biopsy in pregnant patients. I would do a sentinel node biopsy in this situation. You are absolutely correct. We do not use the blue dye. The reason being that risk of allergic reaction.
Obviously methylene blue has a much lower risk than the old isosulfan blue, or the Lymphazurin, but there is still that risk and so yeah, we absolutely don't use the blue dye, but we do sentinel node biopsy, and the same thing goes for melanoma in pregnant patients. We will do sentinel lymph node biopsy. So that is an option, and in this case, that's probably what I would have done. Again, in a situation like this, oral examination, I don't think anybody would fault you for saying that I would go straight to the axillary lymph node dissection in this situation.
>> Okay. >> It did throw off what I was going to ask you about what we are going to do if the sentinel nodes are positive, because we didn't do a sentinel node, but in that case, I would do a completion node dissection, again, for the reasons we spoke about before, she's not going to be getting any radiation, so a full node dissection is indicated there. And then the last point was that you got completely correct, if the patient is a candidate for chemotherapy, you can give chemotherapy to a pregnant patient.
And this is a case where potentially if you gave Adriamycin Cytoxan to the patient, you could maybe do the chemotherapy first, get further along in the pregnancy, then do breast conservation, and deliver, and then give the radiation after the patient has delivered the baby. So sometimes there is an indication for neoadjuvant chemotherapy. In this situation especially because it may allow a woman who, you're right, she's a little bit early in the second trimester, but let's say she'd been a little further along, it may allow a patient to avoid the mastectomy by doing the chemotherapy, but of course, and you go this completely right, you're not going to give chemotherapy to someone who doesn't need chemotherapy, so you wouldn't have given it in the first scenario, where she was ERPR positive, you're going to give it to this patient who is triple negative, because we're going to be recommending chemotherapy regardless.
And then the other thing is, you're absolutely right. It's an option for her, but there's nothing wrong with going forward with the same plan, doing the mastectomy, and then doing the chemotherapy afterwards. So these are options for patients that you can discuss. But there's nothing wrong with going forward with surgery as well. >> Cool. >> Sound good? >> Yeah, sounds good. >> Yeah, the breast cancer in pregnancy is a difficult one.
It's always-- >> That was-- >> Just, you know, keep in mind, you can't give radiation, can't give Tamoxifen, cannot give her Ceptin. You can give chemotherapy. You can get mammograms. You cannot get CT scans or bone scans. And I think you got all that correct. >> Okay.
>> All right. Should we do one more? >> I'm game. It's up to you, sir. >> [Laughs] Well, I can do it. >> Let's do it. >> All right, we'll do one more. It won't be too long, but we'll go back, let's have a-- are you ready? >> Yeah.
>> Okay all right. I didn't know if you needed a deep cleansing breath or something [laughter]. A 52-year-old female presents to your office. She has got a 2 centimeter nodule in her left groin. It is just inferior to the inguinal ligament. It's not tender, and again, no other symptoms associated with it. This is an incidental finding, but on examination, it feels like a palpable lymph node in the groin.
>> Okay. So any time I have a patient with a palpable lymph node, I just proceed with a pretty thorough history and physical. I would evaluate one, the limb that it is affecting, is it in the groin, I would evaluate the limb, determine if there is any evidence of any infection distally, if there is any evidence of any skin lesions. Evaluate to see if she has ever had symptoms related to this groin, if she's ever had any procedures on this limb, or this groin, and then go from there.
>> Okay she's never had any surgical procedures. She's had no recent trauma. There is no evidence of infection. She has been in good health otherwise, and the limb is fine. >> Okay. I'll do review of her past medical history, surgical history, and also then focus on the family history which would include-- and a personal history in relation to any cancers. I would talk to her about any recent weight loss, fevers, chills, anything like that.
>> All negative. >> Okay. All right. So then I'd move on to a physical examination. I would do a close examination of her groin, evaluating for any obvious findings, as well as a thorough examination of her skin, scalp, and whatnot. >> And full skin examination is negative. You really did a thorough job, and you found no atypical lesions, no melanocytic lesions, nothing abnormal on skin examination.
>> Okay. One other thing I would want to do, especially in the setting of inguinal lymphadenopathy would be examination of the perineum, a digital rectal exam, to see if there's any other obvious findings. >> And yeah, all negative. >> Okay. All right, so we have a patient who has lymphadenopathy, and may have cancer with unknown primary, so for me, I would want to move forward with a workup, which would include fine needle aspiration to determine the possible primary source.
>> Okay. >> And then, from there, I'd move forward for further staging. >> Okay, so it will be FNA returns, and this is probably not going to be a surprise, as malignant melanoma. >> Okay. All right. So now we have a positive lymph node, and we have no other evidence of the primary. So I would work up the patient for staging. Specifically I would do a whole body PET CT. >> Okay.
>> And then I would possibly even consider MRI of the brain if the patient is having any symptoms, and I would even consider colonoscopy. >> Okay. So you get a PET scan. And it lights up in the groin, not unexpectedly. And the rest of that study is negative. She has no neurologic symptoms. Did you still want to do a colonoscopy even though the rest of the PET scan was negative? >> How old is the patient? >> The patient is 52.
>> Okay, we can get that later. But for now-- >> Okay. >> Since it's negative, we don't necessarily need it. >> Okay so PET scan is isolated to the left groin. FNA is positive for malignant melanoma. Full skin examination shows no evidence of primary. >> Okay. So at this point, this patient has possible stage three disease, maybe. Doesn't look like stage four disease.
I was unable to find the primary. So in this particular case, I would plan to move forward with a lymph node dissection of the inguinal region. >> All right. I won't ask you to describe the step by step inguinal node dissection, although you know that could be a question on the orals. But what type of node dissection did you want to do? >> I would do the superficial and deep node dissection.
>> Okay. So you're going to take the iliac nodes, the pelvic nodes as well. >> Yeah. >> Okay. So you do that, and your pathology comes back showing three positive nodes out of 14 in the superficial dissection in the inguinal femoral dissection. And then for the deep dissection, there were another 8 nodes, these were all negative. >> Okay. >> Patient is healing up well-- >> So for this-- mm-hm. All right, so for this patient, I would move forward with a discussion at the Multidisciplinary Tumor Board at my institution to determine eligibility for any potential trials, but then specifically, I would want to consider options such as Interferon or ipilimumab for this patient.
>> Okay. Anything else that is an option for adjuvant therapy in this situation? >> There are-- yes, there are. I would say that-- >> Yes, I meant Interferon and ipilimumab are options, I was saying in addition, are there anything else? >> Regional radiation. >> Okay. Excellent. >> And then you know, I would say that's the only other one that comes to mind. >> All right.
So yes, these are all options that we'd need a discussion with the patient, but let's back up again. I like backing up on oral exam, just when you think you're at the end [chuckling] they are such a cruel exam. Okay, let's back up again, and say instead of a 2 centimeter mobile mass in the groin, it's now a 5 centimeter, fixed mass in the groin, and you've got some imaging on it, and in this case, you've got a dedicated CT scan, and it shows that it may be involving the neurovascular structures.
>> Yeah. >> How would you handle this situation? >> So this-- >> And the distant imaging is still negative. >> All right. >> So there's still no evidence of any stage four disease. >> All right, so in this patient they may be a candidate for systemic therapy. Or neoadjuvant chemo, and then proceeding with, or not chemo, but Interferon Alpha, and then proceeding with a node dissection, just to reduce the morbidity associated with a lymph node dissection.
>> All right, are there any tests you might want to get? Anything else you would want to order or do as you're weighing the possibility of doing sort of neoadjuvant therapy? >> Like testing for [inaudible], I would consider that-- >> Ah, excellent. So yes, I would agree with that. Let's talk about that a little bit. Again, good job. I think you did a very good workup of a patient with a palpable node, especially at this point, you know, you have me as an examiner it's easy because you know I'm probably heading toward melanoma, but it's important in these situations, especially if you know who your examiner is, or you have an inkling of what direction they're going in, to not move too quickly and not sort of jump ahead of yourself, and make sort of those predetermined conclusions.
This is a patient with a palpable node, which could be any number of things. It could be infectious, but it also could be any number of malignancies, and I think you did a very good job of working that up. You asked about the B symptoms, because obviously lymphoma is always going to be a consideration in these patients. And I think the trick, or at least the trap that sometimes people fall into, they get the FNA, it comes back as just lymphocytes, and people say okay it's a reactive node, I'm not worried about it.
It's important to remember FNA cannot differentiate between a reactive node and a lymphoma, so you still need to do something else, typically an excisional biopsy. But I would always still start with the FNA. You don't want to jump right to an excisional biopsy, because that can make your subsequent dissection more difficult. But you did all of that perfectly. I very much like that in addition to the full skin examination you knew to do the perineum, to do an anorectal exam, to do a gynecologic examination, because you're exactly right, particularly if you get the FNA back, and it's melanoma, and you can't find a cutaneous melanoma, you can have a mucosal melanoma, and these are other areas where you may identify that.
So it's good that you do that on your examination. Complete lymph node dissection-- yes. Occult primary melanoma, that is the step. You want to make sure you get staging studies. It can be either a dedicated CT scan or PET scan. I like that you got a PET scan in this situation, particularly with the occult disease, because it may lead you in a different direction, and sometimes you'll see a little bit of uptake, for instance in the colon, or somewhere, and that might prompt other studies like a colonoscopy.
But in this case, we have a true occult primary melanoma. You did a completely node dissection. I would agree, a superficial and deep dissection in this situation is indicated. This is a controversial area. I don't think you can give a wrong answer. There are some people that would say in the absence of any imaging findings, in the iliac or pelvic nodes, they would just do a superficial node dissection. And I do that in some cases. And in other cases, particularly here with a younger patient, I would do the superficial and the deep.
Some people would do it for any sort of palpable disease in the groin. Some people go by Cloquet's node, whether that's positive or not. I actually think that's falling a little bit by the wayside, especially because the imaging has gotten so much better. But these are all reasonable answers. The patient comes back with three positive nodes. I think you got it all correct. In this situation, adjuvant Interferon is an option. Adjuvant ipilimumab is an option.
There are a lot of pros and cons to these. It's probably beyond the scope of the oral examination or this podcast to really get into a discussion of that, but I would be happy to do it at some other time. But I love that you mentioned clinical trial as the first option, because you're right, we have a lot of clinical trials, and a lot of answers that we need, and we try to encourage patients to consider some of the ongoing clinical trials. I think it's also important that you knew-- with a little prompting, but you did know, that adjuvant radiation is an option for patients with sort of more worrisome disease.
There is a trial from Australia and New Zealand that clearly demonstrates that adjuvant radiation will improve regional control in higher risk patients, and this would be a high risk patient. It is important to keep in mind, it does not improve overall survival. So just like with the dissection for the sentinel node positive patient, sometimes it gets into that conversation of what are the benefits of regional control in the absence of overall survival. And again, that might be different, depending on the patient's body habitus, the patient's co-morbidities, the patient's age, as well as what basin we're talking about.
The neck, the axilla, the groin. Because the morbidity of the radiation is a lot different in each basin, and the benefits of regional control are a lot different in the different basins. As well as the morbidity of the radiation. So all of that excellent, outstanding. Now, we went back and we gave you what could either be described as a borderline resectable lesion or a unresectable, an unresectable lesion, I apologize for the poor grammar, for the kids listening at home. But you had mentioned that they could be candidates for neoadjuvant interferon.
That's probably not something most people would consider. There were some trials of that, it didn't really show much benefit. I don't think most people would really, in today's era of systemic agents, think about using Interferon. I think the two options that you really have in this situation are targeted therapies for B mutations and immunotherapies. And I know a lot of this gets really confusing for surgical residents, and the idea being, well, why do I need to know this? It's surgery, because I'm not going into medical oncology, but I think it's really important that surgeons know about what the systemic therapy options are in these situations for a few reasons.
One, because this is a situation where it might be really helpful in terms of neoadjuvant therapy, and taking a patient who is borderline resectable and turning them into resectable, or unresectable, and turning them into resectable. But there are also some other issues related to them, in terms of the timing of the surgery. For example, it's important to know that in these patients, you've got to send off some tissue for BRAF, because you need to know if they have the mutation, or if they're wild type, to know whether or not BRAF mech inhibition is a possibility in the neoadjuvant setting.
If it is, it's excellent. You get these dramatic responses. But you make sure that your surgery is timed so that you can get the patient into the operating room quickly. Because unfortunately, when patients do start to recur, they can recur quickly, and you can have situations where if you delay your surgery, you can go from unresectable to resectable and back to unresectable in a relatively short period of time. If they're wild type, if they're not eligible for targeted therapy, then immunotherapy would be the anti-CTLA4 or anti-PD1 therapies, it's really your best option.
Those, again, a little bit tricky because not everybody responds. Response rates aren't nearly as high as they are with targeted therapies, and sometimes, things can get worse before they get better, even in patients who are going to respond, and if you have somebody who is borderline resectable, it can sometimes be a challenge as to whether or not to go forward with surgery, or take a risk on neoadjuvant therapy that either might not work, or the patient may progress or advance during that period of time, and you now went from borderline resectable to unresectable. So I don't think you need to know much about it for the oral examinations, but I think you just need to know that those systemic therapy options, what they are, and know to get BRAF testing, and know that this is a consideration in those patients.
And I think you knew all of that. So that was an excellent job. >> Well, thank you again Dr. Sable, for taking time out on your Sunday night. This is extremely educational, and we really appreciate it. >> Absolutely, it's my pleasure. Thanks for having me. >> And thanks again Bahag. >> You got it, thanks guys. Appreciate letting me be on the show.
That was exciting. >> Until next time, dominate the day! [ Music ]