peri-lung nodes

Brian, my "take" on surgery is pretty simple. To date, surgery is the ONLY treatment that is 100% effective at killing tumors in every individual. Therefore, if surgery is possible and safe, that should be the first choice. To me, it makes no sense to leave one or a few tumors in place in the hopes that some treatment or trial will work. Why do that? 

Unfortunately, melanoma being what it is, even with surgery there is a possibility that the melanoma will be back some day and be inoperable. That is when I would go for targeted radiation, systemic treatment and/or a clinical trial.

Pat, what you say does make sense but I just don’t think it’s as clear cut (no pun intended) decision as it use to be with the advancement of treatments.  Here’s just a few thoughts I might consider if I were in SB’s shoes.

1. I know some stage IVers go years between surgeries and a lucky few live quite a while with this strategy but I don’t think there’s many that make it past the 10 year mark without systemic treatment.  I believe this is SB’s first scan since the VATs surgery so I’m assuming at around 3 – 6 months is the first reoccurrence.  Who knows if that’s any indication for the timing of the next recurrence but it’s something to consider.  If I had gone 2 or 3+ years since my VATs then I would definitely be more inclined to cut it out again.
2. Also based on the quick recurrence if I had a chance to get into a IPI/Nivo trial now I might take it because if I did reoccur in 3 – 6 months who knows if a IPI/Nivo trial would be available then.  I know IPI/Nivo isn’t the only show in town but it’s hard to argue that it’s not the best show in town right now.  Unless something dramatic occurs we are probably still looking at 12 – 18 months before Nivo is FDA approved so if I reoccurred before then I would be rolling the dice that I could get into a Nivo trial.
3. One tough thing about being stage IV NED is that you really don’t have any viable treatment options even though it is almost certain to come back.   Like you said surgery is great for getting 100% of the tumor but not 100% of the melanoma cells.  With such a low tumor burden one option I would ask my onc would be to get an ipi infusion immediately, 3 weeks later another ipi infusion and then rescan.   If things are stable or improving I would go with 2 more ipi infusion and then scan again.  After each scan if the node is progressing, which is definitely a possibility with the delayed response of ipi, you could go with the surgery at that point but at least you have the possibility of getting some benefit of ipi that you wouldn’t get to have if you go with surgery first.

Those are just a few things I would consider.  Like any melanoma treatment option the best one you personally believe gives you the best chance.  Wish you the best SB and good luck on Monday with your appointments.

Brian

Pat, what you say does make sense but I just don’t think it’s as clear cut (no pun intended) decision as it use to be with the advancement of treatments.  Here’s just a few thoughts I might consider if I were in SB’s shoes.

1. I know some stage IVers go years between surgeries and a lucky few live quite a while with this strategy but I don’t think there’s many that make it past the 10 year mark without systemic treatment.  I believe this is SB’s first scan since the VATs surgery so I’m assuming at around 3 – 6 months is the first reoccurrence.  Who knows if that’s any indication for the timing of the next recurrence but it’s something to consider.  If I had gone 2 or 3+ years since my VATs then I would definitely be more inclined to cut it out again.
2. Also based on the quick recurrence if I had a chance to get into a IPI/Nivo trial now I might take it because if I did reoccur in 3 – 6 months who knows if a IPI/Nivo trial would be available then.  I know IPI/Nivo isn’t the only show in town but it’s hard to argue that it’s not the best show in town right now.  Unless something dramatic occurs we are probably still looking at 12 – 18 months before Nivo is FDA approved so if I reoccurred before then I would be rolling the dice that I could get into a Nivo trial.
3. One tough thing about being stage IV NED is that you really don’t have any viable treatment options even though it is almost certain to come back.   Like you said surgery is great for getting 100% of the tumor but not 100% of the melanoma cells.  With such a low tumor burden one option I would ask my onc would be to get an ipi infusion immediately, 3 weeks later another ipi infusion and then rescan.   If things are stable or improving I would go with 2 more ipi infusion and then scan again.  After each scan if the node is progressing, which is definitely a possibility with the delayed response of ipi, you could go with the surgery at that point but at least you have the possibility of getting some benefit of ipi that you wouldn’t get to have if you go with surgery first.

Those are just a few things I would consider.  Like any melanoma treatment option the best one you personally believe gives you the best chance.  Wish you the best SB and good luck on Monday with your appointments.

Brian

Pat, what you say does make sense but I just don’t think it’s as clear cut (no pun intended) decision as it use to be with the advancement of treatments.  Here’s just a few thoughts I might consider if I were in SB’s shoes.

1. I know some stage IVers go years between surgeries and a lucky few live quite a while with this strategy but I don’t think there’s many that make it past the 10 year mark without systemic treatment.  I believe this is SB’s first scan since the VATs surgery so I’m assuming at around 3 – 6 months is the first reoccurrence.  Who knows if that’s any indication for the timing of the next recurrence but it’s something to consider.  If I had gone 2 or 3+ years since my VATs then I would definitely be more inclined to cut it out again.
2. Also based on the quick recurrence if I had a chance to get into a IPI/Nivo trial now I might take it because if I did reoccur in 3 – 6 months who knows if a IPI/Nivo trial would be available then.  I know IPI/Nivo isn’t the only show in town but it’s hard to argue that it’s not the best show in town right now.  Unless something dramatic occurs we are probably still looking at 12 – 18 months before Nivo is FDA approved so if I reoccurred before then I would be rolling the dice that I could get into a Nivo trial.
3. One tough thing about being stage IV NED is that you really don’t have any viable treatment options even though it is almost certain to come back.   Like you said surgery is great for getting 100% of the tumor but not 100% of the melanoma cells.  With such a low tumor burden one option I would ask my onc would be to get an ipi infusion immediately, 3 weeks later another ipi infusion and then rescan.   If things are stable or improving I would go with 2 more ipi infusion and then scan again.  After each scan if the node is progressing, which is definitely a possibility with the delayed response of ipi, you could go with the surgery at that point but at least you have the possibility of getting some benefit of ipi that you wouldn’t get to have if you go with surgery first.

Those are just a few things I would consider.  Like any melanoma treatment option the best one you personally believe gives you the best chance.  Wish you the best SB and good luck on Monday with your appointments.

Brian

Brain, you bring up some very good points here. You remind me of the old agage: "All generalizations are useless, including this one." Perhaps surgery is not ALWAYS the best recourse.

The original poster did not say anything about his/her original pathology report (especially mitotic index), original staging, treatment history, or BRAF status. All of those would definitely factor into the treatment decision now.

However, the fact that this recurrence (if it is a recurrence– a PET scan is not enough to determine that) happened so quickly after the first surgery could indicate an aggressive tumor. In that case, if she has an opportunity to get into an Ipi/Nivo trial it would certainly be worth considering. 

So I revise my original statement to be, "Surgery, where possible and safe, is ALMOST always my first choice." 

Thanks for your thoughtful post.

Brain, you bring up some very good points here. You remind me of the old agage: "All generalizations are useless, including this one." Perhaps surgery is not ALWAYS the best recourse.

The original poster did not say anything about his/her original pathology report (especially mitotic index), original staging, treatment history, or BRAF status. All of those would definitely factor into the treatment decision now.

However, the fact that this recurrence (if it is a recurrence– a PET scan is not enough to determine that) happened so quickly after the first surgery could indicate an aggressive tumor. In that case, if she has an opportunity to get into an Ipi/Nivo trial it would certainly be worth considering. 

So I revise my original statement to be, "Surgery, where possible and safe, is ALMOST always my first choice." 

Thanks for your thoughtful post.

Brain, you bring up some very good points here. You remind me of the old agage: "All generalizations are useless, including this one." Perhaps surgery is not ALWAYS the best recourse.

The original poster did not say anything about his/her original pathology report (especially mitotic index), original staging, treatment history, or BRAF status. All of those would definitely factor into the treatment decision now.

However, the fact that this recurrence (if it is a recurrence– a PET scan is not enough to determine that) happened so quickly after the first surgery could indicate an aggressive tumor. In that case, if she has an opportunity to get into an Ipi/Nivo trial it would certainly be worth considering. 

So I revise my original statement to be, "Surgery, where possible and safe, is ALMOST always my first choice." 

Thanks for your thoughtful post.

Brian, my "take" on surgery is pretty simple. To date, surgery is the ONLY treatment that is 100% effective at killing tumors in every individual. Therefore, if surgery is possible and safe, that should be the first choice. To me, it makes no sense to leave one or a few tumors in place in the hopes that some treatment or trial will work. Why do that? 

Unfortunately, melanoma being what it is, even with surgery there is a possibility that the melanoma will be back some day and be inoperable. That is when I would go for targeted radiation, systemic treatment and/or a clinical trial.

Brian, my "take" on surgery is pretty simple. To date, surgery is the ONLY treatment that is 100% effective at killing tumors in every individual. Therefore, if surgery is possible and safe, that should be the first choice. To me, it makes no sense to leave one or a few tumors in place in the hopes that some treatment or trial will work. Why do that? 

Unfortunately, melanoma being what it is, even with surgery there is a possibility that the melanoma will be back some day and be inoperable. That is when I would go for targeted radiation, systemic treatment and/or a clinical trial.