Review of Answer Choices (Correct Answer in Green):
A. A patient who had a local wide excision of a 1.3 mm thick, non-ulcerated melanoma with negative SLNB.
B. A patient who had a local wide excision of a 2.5 mm thick, ulcerated melanoma with negative SLNB.
C. A patient who had a local wide excision of a 1.7 mm thick, non-ulcerated melanoma and axillary lymph node dissection.
D. A patient who had a local wide excision of a 4.1 mm thick, ulcerated melanoma and axillary lymph node dissection with some evidence of distant organ metastasis.
Explanation:
The primary goals of adjuvant immunotherapy are to eliminate residual microscopic melanoma cells via the immune system, to reduce the risk of future cancer recurrence, and to improve the overall chance of cure. The major target population for adjuvant therapy is patients with resected high-risk stage II or III melanoma (you can refer back to the 8th Edition of the AJCC Staging System for Melanoma).
A. A patient who had a local wide excision of a 1.3 mm thick, non-ulcerated melanoma with negative SLNB: The majority of patients diagnosed with melanoma present with stage I or IIA disease (≤ 2 mm in thickness with ulceration, or ≤ 4 mm in thickness without ulceration) and a negative SLNB. Surgery is usually curative in these patients and adjuvant therapy is not indicated.
B. A patient who had a local wide excision of a 2.5 mm thick, ulcerated melanoma with negative SLNB: Patients with a negative SLNB but high-risk features in their primary tumour are at increased risk of recurrence. High-risk primary tumours are those that are > 4 mm thick or > 2 mm thick with ulceration. We would consider adjuvant immunotherapy in these patients.
C. A patient who had a local wide excision of a 1.7 mm thick, non-ulcerated melanoma and axillary lymph node dissection: This patient had lymph node involvement, which automatically puts them at stage III disease or higher. In this case, one year of adjuvant immunotherapy is indicated.
D. A patient who had a local wide excision of a 4.1 mm thick, ulcerated melanoma and axillary lymph node dissection with some evidence of distant organ metastasis: This patient has some evidence of distant organ metastasis, which puts them at stage IV disease. Once this patient has undergone definitive treatment for all sites of disease, one year of adjuvant immunotherapy is indicated.