ANNUAL REPORT: 2013

SKIN CANCER

Cancer Committee Members Audrey Baker, CTR

Becky Franks

David A. Koeplin, MD

Benjamin L. Blend, MD

Janice Garcia

Liz Lewis

Kathryn Borgenicht, MD

Andrew W. Grace, MD

Jo May, RT

Deanna Brame, FNP

Spencer Green, MS, MBA(HA)

Kenneth May, MD, PhD

Esther Campbell

Brenda Greenfield, RN

Cindy McGinnis

Cindy Carter, PA-C, CBPN-IC

Wendy Gwinner, MSW

Kenneth Mottram, D.Min. BCC

Annie Castillo, MD

R. Taylor Handley, MD

David L. Parks, MD

Kendall Child, FNP-C

Ronna Henderson

J. Bruce Robertson, MD

Jan Davis

Jack O. Hensold, MD

Justin Short, MSW, MPH

Justine DeRousse, PA-C

Jean Joiner

April Sondag, PharmD

Kaitlin Drake, RN

James A. Jutzy, MD

Cheri Wells, SLP

Kevin Duwe, MD

Nancy Kinzler, PharmD

TABLE OF CONTENTS Introduction................................................................................... 1 Focus on Skin Cancer: Spotlight on Melanoma................................. 2 Skin Cancer Report for Bozeman, Montana...................................... 5 My Journey with Melanoma........................................................... 6 Skin Cancer Screening and Treatment.............................................. 9 Surgical Perspectives on Malignant Melanoma................................ 12 Radiation Therapy and Melanoma................................................... 14 Cancer Registry............................................................................. 16

INTRODUCTION 2013 was a year of exciting growth at Bozeman Deaconess Cancer Center, with the completion of one major expansion project and planning for another. All the dust, disruption and relocation are well worth the effort, however, as each project will allow us to provide patients with up-to-date professional medical services in soothing surroundings. Our building expansion project to construct a new vault for our new Varian Trilogy linear accelerator was completed, and the equipment was installed. Our first patient received radiation treatment through the new system, on January 13 of 2014. The linear accelerator is equipped with “on-board imaging,” a built-in CT scanner that enables medical staff to provide more accurate and efficient treatments directly to tumors while sparing healthy surrounding tissue. While construction ensued in Radiation Oncology, we have been planning for more construction in Medical Oncology and Infusion. The $2.3 million project, funded in large part by donations through Bozeman Deaconess Foundation, will boost the number of infusion chairs from 12 to 17. The project also will add two private infusion rooms, increase the number of examination rooms from 6 to 11 and double the size of the oncology pharmacy and laboratory spaces. At the infusion center, treatments have tripled in volume since 2008. Therefore, this expansion comes in response to the greatly increased demand for our services, which is projected to continue. Construction is slated to be finished by the end of 2014. This year, our annual report features a special focus on skin cancer, highlighting scientific, medical and community information. Oncologists, surgeons, providers, and community cancer specialists have contributed to this year’s report to provide a comprehensive look at the specific challenges, research, treatments and services for skin cancers we treat at Bozeman Deaconess Cancer Center and through our affiliated partners. 1

Focus on Skin Cancer: Spotlight on Melanoma By: Jason L. Blaser, MD Dermatology & Dermatopathology Skin cancer is the most common form of cancer in the United States. Both non-melanoma skin cancer and malignant melanoma continue to present a significant public health problem in our community and country. The three major types of skin cancer include basal cell carcinoma, squamous cell carcinoma, and the more serious malignant melanoma. The National Cancer Institute (NCI) estimates that 76,690 Americans were diagnosed with melanoma and 9,480 died from the disease in 2013. The NCI defines melanoma as a form of cancer that begins in melanocytes, which are the cells that produce the pigment melanin, and are derived from the neural crest. Although most melanomas arise in the skin, they may also arise from mucosal surfaces or at other sites in which neural crest cells migrate. The diagnosis of malignant melanoma requires examination of the skin and attention to any suspicious lesions followed by a biopsy/excision/removal and histological evaluation. We are all familiar with the “ABCDE”s of pigmented lesions that we discuss with our patients, but oftentimes malignant melanoma can be found in lesions that do not meet this mnemonic and/or may not be brought to our attention by our patients; therefore, full body skin exam is always recommended to evaluate all of the patient’s skin. Dermoscopy is a noninvasive technique to evaluate a lesion by its color; blood vessel pattern; and microstructures located in the epidermis, dermal epidermal junction, and papillary dermis which may not be visible with the naked eye. This can help the clinician in determining which lesions should be biopsied and which ones can be followed clinically. The pathology of malignant melanoma can also be quite varied. The most common type is superficial spreading malignant melanoma which begins as the horizontal growth phase (in situ component) and at some point becomes invasive (vertical growth phase). Another type of melanoma is lentigo maligna which is usually seen on chronically sun-damaged skin and also presents as in situ but may become invasive (lentigo maligna melanoma). Nodular melanoma does not have an in situ component and presents as a pigmented or non-pigmented papule or nodule in the dermis and has been postulated to originate from the melanocytes at the base of the hair follicle. Desmoplastic melanoma also arises in chronically sun-damaged skin and may or may not have an in situ component, typically these present as a scar-like area associated with or without a pigmented macule. This type of melanoma can be very subtle from the clinical and histological standpoint and can often be overlooked as a scar. Amela2

notic melanoma can present as a new non-descript flesh colored or pink papule and is often overlooked clinically due to its benign appearance. The diagnosis of malignant melanoma should be classified as to which type, depth of invasion (Breslow’s depth and Clark’s level), presence or absence of ulceration, mitotic rate, regression, and satellitosis. The standard of care for most melanomas regardless of subtype and classification is surgical excision. The margins are determined by the type of melanoma and the depth of invasion. Melanoma in situ is excised with 0.5-0.9cm margins and invasive melanoma, depending on the Breslow’s depth, is excised with 1cm-several centimeters margins. Lentigo maligna can be either excised with a 0.5-0.9 mm margins or may be treated with topical Aldara (Imiquimod) or Mohs Micrographic Surgery. As termed by the 2012 appropriate use criteria, Mohs Micrographic Skin Cancer Surgery is a technique for the removal of complex or ill-defined skin cancer with histological examination of 100% of the surgical margins where the surgeon also performs the pathological examination of the margin. Mohs surgery is most commonly employed in non-melanoma skin cancers (basal cell carcinoma and squamous cell carcinoma), but in recent years has been used at some surgery centers for treatment of lentigo maligna (melanoma in situ). It will often require immunohistochemical stains which may take several hours to complete. Only one to two stages can be done on any given day due to this staining process; therefore, surgery may require several days to clear the tumor before closure can take place. Sentinel lymph node biopsy (SLNB) and complete lymph node dissection continues to be a topic of debate with strong advocates on both sides. SLNB is an option for intermediate thickness melanomas, Breslow’s depth of 1mm-3mm thickness. Most advocates agree that SNLB is more of a prognostic tool and may assist in assigning patients for clinical trials. All patients with malignant melanoma approaching 1 mm or greater should be given the option for SLNB. In addition patients with thin melanomas,