A 63-Year-Old Man With Metastatic Melanoma and Typical Workup Strategies at Diagnosis


Expert oncologist Sajeve Thomas, MD, reviews the diagnosis and first-line management of a patient who presents with metastatic melanoma.


Sajeve S. Thomas, MD: My name is Sajeve Thomas, medical oncologist at the Orlando Health [Cancer] Institute [in Florida]. I’ve been in practice for the last 10 years. I primarily treat melanoma sarcoma with about 67% of my practice, and then 30% of my practice is gastrointestinal malignancy. I am the principal investigator for all the melanoma trials at our site.

This is a 63-year-old man presenting with a 4.2-mm-thick primary tumor on the skin of the lower abdomen. He’s known to spend a lot of time on his boat and experienced multiple blistering sunburns as an adult. His performance status is at an ECOG 0. He had a sentinel lymph node biopsy that revealed 1 positive inguinal lymph node. It sounds like, on a CT staging scan, he was found to have 1 hypodense hepatic left lobe lesion. This was biopsy-proven to be metastatic melanoma. He had a brain scan that was negative for metastases. The serum LDH was 613. He did have a next-generation sequencing [NGS] study that showed no targetable mutation. This was in June of 2022. In July of 2022, after discussing the treatment options, this patient opted to do nivolumab and relatlimab and was scheduled for follow-up visits every 3 months. In October 2022, which would be his 3-month follow-up visit, a CT scan was done that showed that the hepatic lesion was decreasing in size, no new metastases. He was experiencing some itchy rash on his arms and was given some topical steroid cream and an oral antihistamine.

In my practice, I see a full spectrum of patients. I see patients that have diffuse disease throughout all their organs, including or not including the brain. I can see patients that have very limited disease to their brain, lung, or liver, sometimes even resected out. I can see patients who have limb-only disease, skin-only metastases, and in these cases the option for treatment is a bit different or can vary. That would be the typical patient that we see, somebody who has metastatic disease to their lung, liver, or the bone without any evidence of brain metastases.

At the time of diagnosis, we normally would get an NGS [study]. In addition to NGS, we’re actually checking circulating tumor DNA [ctDNA] as another way of assessment, and this is done prospectively on a clinical trial as well. You can kind of get both at the same time. So NGS, circulating tumor DNA, occasionally we’ll checkup PD-L1 and also LDH. They might be helpful in selecting some of the treatments that are available for patients, but for most patients, especially when we’re talking about clinical trials, I have 2 or 3 first-line trials. Biomarker assessment is not necessarily needed, but one thing that is important to have is the BRAF status before we start clinical trials.

For clinical trials, we do need the BRAF status. Certainly if we’re sending tissue off, there may be a necessity of PD-L1 or other biomarker that’s needed, but outside of clinical trials, I do not. Especially in those situations, I tend to start with the new therapy first if we’re not going to discuss clinical trials, and most often it’s clinical factors that influence the decisions of what treatment options we’ll go with.

For anybody I see as a brand-new patient with a stage IV metastatic disease or unresected melanoma, I usually get a baseline PET [positron emission tomography] just to get a sense of the disease elsewhere, especially in the bones or places we’re not really paying attention to. If there was something in the spine, we may act on that a little bit earlier with radiotherapy. If there’s something in the weight-bearing bones, you may want to act on that, especially when melanoma likes to go to the bones, but certainly just sort of a nice staging scan. Certainly, if you don’t have a PET, a good CT of the chest and an MRI of the brain is a must, and then making sure we check those brain scans every 3 months while they’re on therapy is important since there is a high propensity for melanoma to go the brain. NGS, ctDNA as well as baseline, and then a broad spectrum of labs—CBC [complete blood cell count], CMP. I will often check their baseline thyroid function just to make sure there’s no preexisting issues, but a lot of those labs will follow over time, and an LDH.

Transcript edited for clarity.

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