Case by case: Metastatic Melanoma

Australia has the highest rate of skin cancer in the world.

Melanoma is a form of cancer that starts from the melanocytes—the cells in the skin that produce melanin— and can occur anywhere on the skin. Melanocytes in the eyes, nervous system and mucous membranes can also become cancerous however these are rare. Melanoma can grow quickly. If left untreated, it may spread to the dermis, where cancer cells can escape and be carried in lymph or blood vessels to other parts of the body.

The most common treatment for melanoma is surgery and this is all that is needed for more than 85 per cent of melanoma patients. Melanoma can be treated most effectively in its early stages, when it is still confined to the top layer of the skin. The deeper a melanoma penetrates into the skin, the greater the risk that it may spread to draining lymph nodes or to other body organs.

Metastatic disease means the melanoma has spread to distant skin sites, to lymph nodes or internal organs. Sometimes metastatic melanoma is called advanced melanoma.

This case study involves a team of specialists from Mater Private Hospital Brisbane including Dr Paul Mainwaring, medical oncologist, Dr Scott Ingram, plastic surgeon, Dr Simon Journeaux, orthopaedic surgeon and Dr Peter Steadman, orthopaedic surgeon.

Scenario

A 24 year old female presented to her GP with a pimple-like lesion on her neck, below her ear. A non-urgent referral was given to the patient. The lesion regressed and the patient didn’t present to her GP again until six months later, by which time she had developed cervical lymphadenopathy.

The GP ordered an urgent fine needle aspiration which was consistent with malignant melanoma. Further tests confirmed metastatic disease in other areas of her body, in particular her right femur, cervical lymph nodes and later, her breast.

Treatment

The woman was referred immediately to Dr Paul Mainwaring by her GP who initiated a treatment plan that included the following procedures and therapies.

Operations

• biopsy of right femur by Dr Simon Journeaux
• proximal femur resection and reconstructive megaprosthesis by Dr Peter Steadman
• left modified radical neck dissection by Dr Scott Ingram.

Post Op

• surgery substituted for radiotherapy to femur and by wide resection improves survival if all staging is clear
• novel immunotherapy monoclonal antibody, followed
• by a course of a combination of chemotherapy and antiangiogenesis inhibitor.

Outcome

Eight months after first presenting to Dr Mainwaring, the patient was in remission. Less than 10 per cent of patients respond to the treatments as well as she did. Doctors believe her result can be greatly attributed to the trial course of combination therapy.