J. Kurtz2, G. Beasley1, K. Kendra1, T. Olencki1, A. Terando1, J. Howard1, D. Agnese1 1Ohio State University,Surgical Oncology,Columbus, OH, USA 2Doctor’s Hospital,General Surgery,Columbus, OH, USA
Introduction: After appropriate initial therapy for patients with stage II-III melanoma, there is no consensus regarding surveillance, thus follow up is highly variable among institutions and individual providers. The NCCN recommends routine clinical exam and consideration of imaging for stage IIB-IIIC every 3-12 months with no distinction between stages. Detection of recurrence is important as novel systemic therapies and surgical resection of recurrence can provide survival benefits.
Methods: We retrospectively reviewed 369 patients with Stage II and III melanoma treated at Ohio State University from 2009-2015 who underwent surgery as primary initial therapy. 246 patients who were followed for a minimum of 6 months after completion of surgical therapy to achieve no evidence of disease status (NED) were included in this analysis while 123 were lost to follow up after surgery and were excluded.
Results: The rate of recurrence for stage IIA/IIB patients was 11% (14/123). Eight of the 14 (57%) recurrences were detected by clinical symptoms or physical exam. Thirty-eight percent (47/123) of stage IIA or IIB patients were followed by clinical exam only while 64% (76/123) were followed with at least 2 serial chest x-rays. The median time to first chest x-ray after NED status was 4.7 months (n=76), median time to second chest-xray after NED status was 12.7 months (n=76), and 66% (50/76) continued to have additional serial chest x-rays. At median follow-up of 35 months for the 123 patients with stage IIA/IIB, there was no difference in survival between those followed clinically (95% (95% CI: 0.88-.99)) versus those followed with at least 2 serial x-rays (96% (95% CI: 0.89-0.98). For stage IIC/IIIA-C patients, recurrence was detected in 24% (29/123) at median follow-up 31.2 months. Imaging detected 51% (15/29) of those recurrences in asymptomatic patients while 40% (14/29) had recurrence detected on imaging with associated clinical findings. Eighty six percent (106/123) of stage IIC/IIIA-C patients were followed with at least 2 serial whole body PET/CT scans or whole body CT scans plus brain MRI; median time between NED status and second scan was 10.3 months. Of stage IIC/stage III patients with recurrence, 68% (19/28) went on to surgical resection of the recurrence while 18 (64%) patients received B-RAF inhibitor therapy, immune blockade therapy, or combination therapy.
Conclusion: For stage IIA and IIB melanoma, surveillance chest x-rays did not improve survival compared to physical exam alone. However for IIC and IIIA-C melanoma, where the recurrence rates are higher, routine whole body imaging detected recurrences not found on clinical exam leading to additional surgery and/or treatment with novel systemic therapies for the majority of patients. Detection of melanoma recurrence is important and specific sub stage should be used to stratify risk and define appropriate follow up.