Dr. VanderWalde: Are you modifying the way that you're doing sentinel node biopsy and/or complete lymph node dissection in this era?
Dr. van Akkooi: Thankfully not yet. We didn’t have to reduce our surgery, so our resources here have been good and we’ve been able to continue our normal practice for these cases. [What] we have discussed within our multidisciplinary team is that if we would have to reduce our surgeries that we would offer the BRAF-mutated melanoma patients with a locally advanced disease rather than upfront surgery, give them BRAF MEK inhibition for a few weeks until the pandemic quiets down before we take them to surgery because we know that this is a safe and effective approach to that. However, one of the big details to that is, obviously, that one of side effects for BRAF MEK inhibition is fevers and chills, and that’s also one of the symptoms for COVID, so that was a bit of a hesitation we had to really offer it, but we said, well, if we really need to, then we’ll take that.
Dr. VanderWalde: Is there a possibility of doing…in a patient with a positive sentinel node, is there the possibility of doing a complete lymph node dissection in the same surgery as opposed to bringing the patient back later? Is that something your pathology departments have been willing to do, or is that not something that’s come up yet?
Dr. van Akkooi: Well, for us,...based on the MSLT-II results, we don't do any routine lymph node dissections anymore for simple node-positive disease, so we’ve not tried that.
Dr. VanderWalde: I think that’s helpful to note because there are still a lot of practices that don't follow MSLT-II routinely. Is that something that you would recommend, trying to do a frozen section that can…similar to what they do in breast cancer...so that you can avoid having that second surgery?
Dr. van Akkooi: Actually, I would rather advise to follow the MSLT-II outcome. Also, these are now going into the ASCO and ESMO and CCN recommendations and guidelines...to not routinely offer a complete lymph node dissection anymore for sentinel node-positive disease. A delayed lymph node dissection for sentinel node-positive disease is just as good as an immediate one, in terms of survival outcomes, so I would actually argue that in this COVID space that would be even more reason not to do an immediate completion lymph node dissection.
Dr. VanderWalde: I think that’s very important guidance. I think that you're…it makes a lot of sense what you're saying, that this is a really good opportunity to really standardized MSLT-II, especially in practices that have not really been taking it at face value. Is there a way that you see in the COVID pandemic to risk-stratify melanomas as to whether or not they are going to ultimately be a lesion that can be waited on versus those that really should be taken care of right away?
Dr. van Akkooi: Yeah, absolutely. As you know, Ari, there are a number of gene expression profiles that are available from commercial entities that offer them. Some are more validated than others, but they use the primary tumor characteristics, like Breslow thickness and ulceration, together with this gene expression profile usually to estimate what the risk is of a patient to have a positive sentinel node. I know across the globe that this has not been brought into most guidelines yet, but this can be an opportunity to use those tests to try to further triage your patients, which ones you really want to continue doing the sentinel node now, and which ones you might consider delaying the sentinel node procedure in.