New techniques bring hope for melanoma patients

A new Yale Medical Group surgeon carefully evaluates early melanoma, while seeking new solutions for patients whose disease has spread.

Mark Faries, MD, examines an new patient for melanoma, one of the fastest growing cancers especially among young women.

(January 2011) By the time he went to see Mark Faries, MD, five years ago, Jim Shanley was at the end of his rope. Shanley had malignant melanoma on his scalp that kept recurring despite several surgeries. Instead of operating again, Dr. Faries injected the lesion with BCG, a tuberculosis vaccine that stimulates a strong immune response and is sometimes useful in treating melanoma. In Shanley’s case, it worked; after several treatments, the melanoma has not reappeared on his scalp.

“I didn’t have any hope at all until I met Dr. Faries,” says Shanley, who now sees the surgeon every six months for a checkup.

The biggest risk factor for melanoma, which can appear anywhere on the surface of the skin, is exposure to ultraviolet radiation. In terms of incidence it is one of the fastest growing cancers, especially among young women, who are the ones most likely to sunbathe and use tanning booths.

A melanoma expert who was recently recruited from the John Wayne Cancer Institute in California, Dr. Faries is combining his well-honed surgical skills with new approaches to offer melanoma patients cutting-edge treatments. He is collaborating with medical oncologists and immunobiologists in a number of clinical trials to develop new forms of immunotherapy, treating patients using an experimental form of chemotherapy that goes directly to the liver in cases where the melanoma has spread there, and testing new ways of assessing the lymph nodes to look for signs of melanoma in them.

“Being able to collaborate on the full spectrum from basic science through all aspects of clinical will allow us to make a lot of progress in treating this cancer,” he says.

Early diagnosis, simpler treatment

Dr. Fairies and colleagues discuss a case. Depending on factors such as thickness of the tumor, he may need to do a sentinel lymph node biopsy to see if cancer has spread.

For melanoma that is caught early, Dr. Faries surgically removes the lesion. “The earlier the melanoma is picked up, the simpler the treatment,” he says. In order to make sure he removes all the cancer cells, he cuts a wide margin around the tumor, leaving a hole that he repairs using reconstructive surgery.

Depending on the thickness and other features of the tumor, Dr. Faries may also need to do a sentinel lymph node biopsy to find out if the cancer has spread. Unlike breast cancer, which normally affects only the lymph nodes under the arm, melanoma can affect lymph nodes located throughout the body, including the groin, neck, near the elbow, behind the knees or on the back. The accuracy of this minimally invasive procedure, which Dr. Faries has performed hundreds of times, can impact the patient’s prognosis.

Currently the standard treatment is to remove all the lymph nodes from an area if melanoma cells are found in even one node. But that may not be necessary, because 80 percent of the time sentinel nodes are the only ones that contain melanoma cells. Dr. Faries is conducting a clinical trial to determine if it makes sense to remove only the node where cancer cells are found rather than removing all of them.

Promising new approaches

Melanoma that has spread used to have a very low cure rate, but Dr. Faries and his colleagues at the Yale Melanoma Program now have several promising approaches at their disposal and are actively involved in clinical trials to develop new ones. “Even for patients who have metastatic disease, there is still a great deal of hope,” he says. “With some of the newer therapies, there’s a real opportunity to help many of them.”

Although Dr. Faries is a surgical oncologist, the newer techniques he uses to treat patients aren’t always surgical. Many of them, such as the treatment he used for Shanley, involve immunotherapy. Dr. Faries is planning a clinical trial involving IgM antibodies that work by binding to proteins circulating in the body and are less taxing on the immune system than other types of antibodies. Another promising immune therapy is the drug ipilimumab, which is currently in clinical trials at Yale. It activates the immune system and is the first drug to ever demonstrate a survival benefit for advanced melanoma.

Metastatic melanoma tends to be unresponsive to chemotherapy, but in cases where it has spread to the liver, Dr. Faries has used an experimental treatment called hepatic perfusion. This allows for the delivery of high doses of chemotherapy directly into the liver where they are concentrated enough to be effective.

Following patients for years

Dr. Faries stays involved with his patients for years, even when they are cancer-free.

Whether he’s surgically removing a lesion or advising a patient on the next course of treatment, Dr. Faries remains involved with his patients for years, following them throughout their treatment and seeing them periodically even when they’re cancer-free.

“Once a melanoma patient, always a melanoma patient,” he says. Shanley, who divides his time between the east and west coasts, first saw Dr. Faries in California and now sees him at Yale. After recently learning that the melanoma had spread to his lung, he consulted with Dr. Faries and underwent extensive surgery to remove it. “Dr. Faries has been very much a part of every aspect of my care,” says Shanley. “His attention has been really important to me.”

Story by Jill Max
Photos by Robert Lisak