› Forums › General Melanoma Community › Surgery vs therapy
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Bubbles.
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- September 8, 2014 at 3:08 am
Just wondering people's thoughts on what is the best course of action. If melanoma is detected in a major organ (lung, liver, spleen, etc) and it is resectable, is that usually the best route to take – go in and get rid of it? Or would one consider some type of therapy (I.e. Yervoy, ipi, etc.)? Not sure of there are any residual affects if it is just taken out.
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- September 8, 2014 at 11:56 am
Generally speaking, I believe if there's a high degree of confidence that the tumor can be resected, that should be part of the treatment along with any adjuvant therapy your doctor may recommend. There are others on this board far more knowledgeable but from what I do know, if you can cut it out, get rid of it.
hope this helps
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- September 8, 2014 at 2:53 pm
I tend to agree, but there isn't a perfect answer. As someone who's had both systemic treatments (3 different ones) as well as more traditional therapies (7 different rounds or radiation, 7 different surgeries), I see the benefit of both at the appropriate times. Fortunately, after my first systemic therapy, I've had relatively low tumor burden, with new metastases only appearing basically one at a time. We've made the decision, with all of my doctors (medical, radiation, surgical, and orthopedic oncology) in agreement, in those situations, to either resect or radiate when possible. It can start to feel like a sadistic game of "whack-a-mole" (no pun intended) and at some point, we may decide that enough is enough and move on to another systemic treatment. I am BRAF positive and have yet to try any of the BRAF medications and haven't used PD-1 yet either, preferring to reserve those for if a time arises that I have something that can't be resected or radiated. Like I said, no perfect answer, it's a fine line and we just take new metastases as they come and try to make the best decision at the time.
Wishing you the best with your decision, Joe
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- September 8, 2014 at 2:53 pm
I tend to agree, but there isn't a perfect answer. As someone who's had both systemic treatments (3 different ones) as well as more traditional therapies (7 different rounds or radiation, 7 different surgeries), I see the benefit of both at the appropriate times. Fortunately, after my first systemic therapy, I've had relatively low tumor burden, with new metastases only appearing basically one at a time. We've made the decision, with all of my doctors (medical, radiation, surgical, and orthopedic oncology) in agreement, in those situations, to either resect or radiate when possible. It can start to feel like a sadistic game of "whack-a-mole" (no pun intended) and at some point, we may decide that enough is enough and move on to another systemic treatment. I am BRAF positive and have yet to try any of the BRAF medications and haven't used PD-1 yet either, preferring to reserve those for if a time arises that I have something that can't be resected or radiated. Like I said, no perfect answer, it's a fine line and we just take new metastases as they come and try to make the best decision at the time.
Wishing you the best with your decision, Joe
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- September 8, 2014 at 2:53 pm
I tend to agree, but there isn't a perfect answer. As someone who's had both systemic treatments (3 different ones) as well as more traditional therapies (7 different rounds or radiation, 7 different surgeries), I see the benefit of both at the appropriate times. Fortunately, after my first systemic therapy, I've had relatively low tumor burden, with new metastases only appearing basically one at a time. We've made the decision, with all of my doctors (medical, radiation, surgical, and orthopedic oncology) in agreement, in those situations, to either resect or radiate when possible. It can start to feel like a sadistic game of "whack-a-mole" (no pun intended) and at some point, we may decide that enough is enough and move on to another systemic treatment. I am BRAF positive and have yet to try any of the BRAF medications and haven't used PD-1 yet either, preferring to reserve those for if a time arises that I have something that can't be resected or radiated. Like I said, no perfect answer, it's a fine line and we just take new metastases as they come and try to make the best decision at the time.
Wishing you the best with your decision, Joe
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- September 8, 2014 at 11:56 am
Generally speaking, I believe if there's a high degree of confidence that the tumor can be resected, that should be part of the treatment along with any adjuvant therapy your doctor may recommend. There are others on this board far more knowledgeable but from what I do know, if you can cut it out, get rid of it.
hope this helps
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- September 8, 2014 at 11:56 am
Generally speaking, I believe if there's a high degree of confidence that the tumor can be resected, that should be part of the treatment along with any adjuvant therapy your doctor may recommend. There are others on this board far more knowledgeable but from what I do know, if you can cut it out, get rid of it.
hope this helps
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- September 8, 2014 at 2:56 pm
I've had the same question and would love to hear others thoughts or experiences. Wondering if going in and resecting it is doing any harm. If you 'cherry pick,' and then are NED, you don't know if there are any microscopic cancer cells lingering out there (but then again, I guess you don't know until they start turning into tumors).
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- September 8, 2014 at 2:56 pm
I've had the same question and would love to hear others thoughts or experiences. Wondering if going in and resecting it is doing any harm. If you 'cherry pick,' and then are NED, you don't know if there are any microscopic cancer cells lingering out there (but then again, I guess you don't know until they start turning into tumors).
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- September 8, 2014 at 2:56 pm
I've had the same question and would love to hear others thoughts or experiences. Wondering if going in and resecting it is doing any harm. If you 'cherry pick,' and then are NED, you don't know if there are any microscopic cancer cells lingering out there (but then again, I guess you don't know until they start turning into tumors).
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- September 8, 2014 at 3:44 pm
To some extent this is a classic example of the adage "to a man with a hammer everything is a nail."
A surgeon, or surgical oncologist, will say that surgery is the only thing that has every cured melanoma. Their natural tendency is to remove the tumor.
A medical oncologist will argue that once the cancer has spread it could be anywhere. The tumor in the distant organ is the only known site, but maybe not the only site. The best approach, under this view, is to offer systemic therapy that can track down those other potential bad cells and get rid of them. The response of the tumor(s) that is visilble serves as an indicator of whether or not the therapy is working. If that tumor is removed surgically, you no longer have a way ot monitoring response. And some turmor may help some therapies work better.
The issue is complicated by the lack of good therapies once the tumor is removed by surgery. In an ideal world we would have great "adjuvant" drugs. The tumor would be removed by surgery, then the adjuvant drugs would b used to mop up any stray cells. We aren't there yet so, like many things in melanoma treatment, it comes down to a judgment call.
Tim–MRF
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- September 8, 2014 at 4:36 pm
Well put Tim. I've been fortunate that each time we've faced this decision, my medical, radiation, surgical, and/or orthopedic oncologists, all of whom are experienced in treating melanoma in their respective specialties, have all been in agreement on the approach, which is a big help — of course, I don't know how much debate goes on behind closed doors, but by the time the options are presented to me, there has been agreement.
Joe
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- September 8, 2014 at 4:36 pm
Well put Tim. I've been fortunate that each time we've faced this decision, my medical, radiation, surgical, and/or orthopedic oncologists, all of whom are experienced in treating melanoma in their respective specialties, have all been in agreement on the approach, which is a big help — of course, I don't know how much debate goes on behind closed doors, but by the time the options are presented to me, there has been agreement.
Joe
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- September 8, 2014 at 4:36 pm
Well put Tim. I've been fortunate that each time we've faced this decision, my medical, radiation, surgical, and/or orthopedic oncologists, all of whom are experienced in treating melanoma in their respective specialties, have all been in agreement on the approach, which is a big help — of course, I don't know how much debate goes on behind closed doors, but by the time the options are presented to me, there has been agreement.
Joe
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- September 8, 2014 at 8:08 pm
Tim-
Oddly enough I was in this situation as I progressed to Stage 4 about a year ago. I split hospitals/doctors between AdvocateLutheran General Dr. Hallmeyer & Richards and Dr. Bilmoria & Wayne at Northwestern as surgical oncologists. Intially the thought was I had local recurrence with lump in scar line in cheek after 2.5 years with no recurrence. Dr. Bilmoria said PET was necessary under the premise of measuring twice and cutting once. Well we all know where story goes…mestastasis to organ(lungs). He called me a Saturday morning and said he wouldn't do surgery and I should do systemic treatment…he would set me up with Kuzel if I wanted or go back to Richards & Hallmeyer, which I did and entered the trial combining ipi & IL-2 as I'm BRAF negative. I also have a close friend who is a surgical onc at James Cancer Center who specializes in melanoma….he said he preferred surgery but admitted as you said that is his mentality as a surgeon…I asked him for 2nd opinion and he said with ipi and pipeline of drugs….given my low tumor burden….systemic treatment may be the magic bullet. Well it'll be 6 months of NED if I get clean scan on Oct 3rd…I had immeadiate results on ipi and went ahead with IL-2 in January….
I think what we need to look at is adjuvant treatments… I wanted surgey and then IL-2 and/or ipi to "take care of body system" or anything "left behind". It didn't make sense to me but I felt as if I had to trust my doctors.
I know there is/was a trial ECOG 1609….my doctors wanted to go strictly systemic….felt it was my best chance at durable response….can you tell us if there are more trials…anything in pipeline for adjuvant treatment outside of interferon which my docs wanted to avoid and if I remember might have been an option in the previously mentioned trial.
I know PD-1 is all the buzz but what else is in pipeline??? I hope I never have to worry about it but you never know and I'm always thinking ahead for myself and future warriors…
Josh
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- September 8, 2014 at 8:08 pm
Tim-
Oddly enough I was in this situation as I progressed to Stage 4 about a year ago. I split hospitals/doctors between AdvocateLutheran General Dr. Hallmeyer & Richards and Dr. Bilmoria & Wayne at Northwestern as surgical oncologists. Intially the thought was I had local recurrence with lump in scar line in cheek after 2.5 years with no recurrence. Dr. Bilmoria said PET was necessary under the premise of measuring twice and cutting once. Well we all know where story goes…mestastasis to organ(lungs). He called me a Saturday morning and said he wouldn't do surgery and I should do systemic treatment…he would set me up with Kuzel if I wanted or go back to Richards & Hallmeyer, which I did and entered the trial combining ipi & IL-2 as I'm BRAF negative. I also have a close friend who is a surgical onc at James Cancer Center who specializes in melanoma….he said he preferred surgery but admitted as you said that is his mentality as a surgeon…I asked him for 2nd opinion and he said with ipi and pipeline of drugs….given my low tumor burden….systemic treatment may be the magic bullet. Well it'll be 6 months of NED if I get clean scan on Oct 3rd…I had immeadiate results on ipi and went ahead with IL-2 in January….
I think what we need to look at is adjuvant treatments… I wanted surgey and then IL-2 and/or ipi to "take care of body system" or anything "left behind". It didn't make sense to me but I felt as if I had to trust my doctors.
I know there is/was a trial ECOG 1609….my doctors wanted to go strictly systemic….felt it was my best chance at durable response….can you tell us if there are more trials…anything in pipeline for adjuvant treatment outside of interferon which my docs wanted to avoid and if I remember might have been an option in the previously mentioned trial.
I know PD-1 is all the buzz but what else is in pipeline??? I hope I never have to worry about it but you never know and I'm always thinking ahead for myself and future warriors…
Josh
-
- September 8, 2014 at 8:08 pm
Tim-
Oddly enough I was in this situation as I progressed to Stage 4 about a year ago. I split hospitals/doctors between AdvocateLutheran General Dr. Hallmeyer & Richards and Dr. Bilmoria & Wayne at Northwestern as surgical oncologists. Intially the thought was I had local recurrence with lump in scar line in cheek after 2.5 years with no recurrence. Dr. Bilmoria said PET was necessary under the premise of measuring twice and cutting once. Well we all know where story goes…mestastasis to organ(lungs). He called me a Saturday morning and said he wouldn't do surgery and I should do systemic treatment…he would set me up with Kuzel if I wanted or go back to Richards & Hallmeyer, which I did and entered the trial combining ipi & IL-2 as I'm BRAF negative. I also have a close friend who is a surgical onc at James Cancer Center who specializes in melanoma….he said he preferred surgery but admitted as you said that is his mentality as a surgeon…I asked him for 2nd opinion and he said with ipi and pipeline of drugs….given my low tumor burden….systemic treatment may be the magic bullet. Well it'll be 6 months of NED if I get clean scan on Oct 3rd…I had immeadiate results on ipi and went ahead with IL-2 in January….
I think what we need to look at is adjuvant treatments… I wanted surgey and then IL-2 and/or ipi to "take care of body system" or anything "left behind". It didn't make sense to me but I felt as if I had to trust my doctors.
I know there is/was a trial ECOG 1609….my doctors wanted to go strictly systemic….felt it was my best chance at durable response….can you tell us if there are more trials…anything in pipeline for adjuvant treatment outside of interferon which my docs wanted to avoid and if I remember might have been an option in the previously mentioned trial.
I know PD-1 is all the buzz but what else is in pipeline??? I hope I never have to worry about it but you never know and I'm always thinking ahead for myself and future warriors…
Josh
-
- September 8, 2014 at 3:44 pm
To some extent this is a classic example of the adage "to a man with a hammer everything is a nail."
A surgeon, or surgical oncologist, will say that surgery is the only thing that has every cured melanoma. Their natural tendency is to remove the tumor.
A medical oncologist will argue that once the cancer has spread it could be anywhere. The tumor in the distant organ is the only known site, but maybe not the only site. The best approach, under this view, is to offer systemic therapy that can track down those other potential bad cells and get rid of them. The response of the tumor(s) that is visilble serves as an indicator of whether or not the therapy is working. If that tumor is removed surgically, you no longer have a way ot monitoring response. And some turmor may help some therapies work better.
The issue is complicated by the lack of good therapies once the tumor is removed by surgery. In an ideal world we would have great "adjuvant" drugs. The tumor would be removed by surgery, then the adjuvant drugs would b used to mop up any stray cells. We aren't there yet so, like many things in melanoma treatment, it comes down to a judgment call.
Tim–MRF
-
- September 8, 2014 at 3:44 pm
To some extent this is a classic example of the adage "to a man with a hammer everything is a nail."
A surgeon, or surgical oncologist, will say that surgery is the only thing that has every cured melanoma. Their natural tendency is to remove the tumor.
A medical oncologist will argue that once the cancer has spread it could be anywhere. The tumor in the distant organ is the only known site, but maybe not the only site. The best approach, under this view, is to offer systemic therapy that can track down those other potential bad cells and get rid of them. The response of the tumor(s) that is visilble serves as an indicator of whether or not the therapy is working. If that tumor is removed surgically, you no longer have a way ot monitoring response. And some turmor may help some therapies work better.
The issue is complicated by the lack of good therapies once the tumor is removed by surgery. In an ideal world we would have great "adjuvant" drugs. The tumor would be removed by surgery, then the adjuvant drugs would b used to mop up any stray cells. We aren't there yet so, like many things in melanoma treatment, it comes down to a judgment call.
Tim–MRF
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- September 9, 2014 at 12:25 am
I think in the future surgery and radiation will be gradually usurped by immuno therapies and drugs. Surgery works sometimes but can also hasten the distant spread of melanoma. As for radiation there is a fair bit of research that suggests it only kills the daugter cancer cells whilst the main stem cells are actually strengthened. I would completely steer clear of all radiation.
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- September 9, 2014 at 12:25 am
I think in the future surgery and radiation will be gradually usurped by immuno therapies and drugs. Surgery works sometimes but can also hasten the distant spread of melanoma. As for radiation there is a fair bit of research that suggests it only kills the daugter cancer cells whilst the main stem cells are actually strengthened. I would completely steer clear of all radiation.
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- September 9, 2014 at 12:25 am
I think in the future surgery and radiation will be gradually usurped by immuno therapies and drugs. Surgery works sometimes but can also hasten the distant spread of melanoma. As for radiation there is a fair bit of research that suggests it only kills the daugter cancer cells whilst the main stem cells are actually strengthened. I would completely steer clear of all radiation.
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- September 9, 2014 at 1:47 am
All of you are right, in that this is a complicated choice. However, data is building that while some folks have a complete response to immunotherapies…no matter their initial tumor burden….more folks respond better to these drugs with the lowest tumor burden possible. So, sometimes debulking with surgery or BRAFi can be very helpful. The NED arm of the nivo trial I am in is also showing this concept to be true….so far….jury is still out…but compared to the 30-40% response rate of nivo, in treatment naive (other than surgery) patients, we NED folks are holding at a greater than an 80% response rate. So we'll see.
I really agree that we need much better, and much more accessible adjuvant meds. To that end, I recently put together this post regarding the current offerings listed as "adjuvants"….not that I am recommending all of them by any means!! http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2014/09/studies-listed-as-adjuvants-for.html
As far as what is new in the pipeline: Anti-PDL1, anti-KIR, second generation BRAFi, possibly LAG3…at least in combo with anti-PD1, and hopefully some intralesional therapies…perhaps not on their own…but in combination with immunotherapies will hopefully prove themselves worthy and be coming soon.
This was an amazing discovery noted in Nature in July: http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2014/08/eif4f-way-to-break-resistance-to-anti.html
So, like most things…get the best advice you can…then decide what you think makes the most sense to you. Wishing you all my best. Celeste
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- September 9, 2014 at 1:47 am
All of you are right, in that this is a complicated choice. However, data is building that while some folks have a complete response to immunotherapies…no matter their initial tumor burden….more folks respond better to these drugs with the lowest tumor burden possible. So, sometimes debulking with surgery or BRAFi can be very helpful. The NED arm of the nivo trial I am in is also showing this concept to be true….so far….jury is still out…but compared to the 30-40% response rate of nivo, in treatment naive (other than surgery) patients, we NED folks are holding at a greater than an 80% response rate. So we'll see.
I really agree that we need much better, and much more accessible adjuvant meds. To that end, I recently put together this post regarding the current offerings listed as "adjuvants"….not that I am recommending all of them by any means!! http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2014/09/studies-listed-as-adjuvants-for.html
As far as what is new in the pipeline: Anti-PDL1, anti-KIR, second generation BRAFi, possibly LAG3…at least in combo with anti-PD1, and hopefully some intralesional therapies…perhaps not on their own…but in combination with immunotherapies will hopefully prove themselves worthy and be coming soon.
This was an amazing discovery noted in Nature in July: http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2014/08/eif4f-way-to-break-resistance-to-anti.html
So, like most things…get the best advice you can…then decide what you think makes the most sense to you. Wishing you all my best. Celeste
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- September 9, 2014 at 1:47 am
All of you are right, in that this is a complicated choice. However, data is building that while some folks have a complete response to immunotherapies…no matter their initial tumor burden….more folks respond better to these drugs with the lowest tumor burden possible. So, sometimes debulking with surgery or BRAFi can be very helpful. The NED arm of the nivo trial I am in is also showing this concept to be true….so far….jury is still out…but compared to the 30-40% response rate of nivo, in treatment naive (other than surgery) patients, we NED folks are holding at a greater than an 80% response rate. So we'll see.
I really agree that we need much better, and much more accessible adjuvant meds. To that end, I recently put together this post regarding the current offerings listed as "adjuvants"….not that I am recommending all of them by any means!! http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2014/09/studies-listed-as-adjuvants-for.html
As far as what is new in the pipeline: Anti-PDL1, anti-KIR, second generation BRAFi, possibly LAG3…at least in combo with anti-PD1, and hopefully some intralesional therapies…perhaps not on their own…but in combination with immunotherapies will hopefully prove themselves worthy and be coming soon.
This was an amazing discovery noted in Nature in July: http://chaoticallypreciselifeloveandmelanoma.blogspot.com/2014/08/eif4f-way-to-break-resistance-to-anti.html
So, like most things…get the best advice you can…then decide what you think makes the most sense to you. Wishing you all my best. Celeste
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