Keytruda the only option? plus Path Report

Posted By
5/14/2018 9:04pm
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Replies: 6

So, got mom's pathology report, following WLE of her right heel for ALM (2cm margins, with skin graft) in February.  (I've also listed the PET scan results below - she has nodal involvement - no biopsy/lymph surgery though.)  Would appreciate any thoughts on the path report - she's 84, staged locally advanced 3C.

She had her third dose of Keytruda today, but there is concern that the tumour has come back in the original site as one section of her heel is not healing after three months, and appears ulcerated. Met with the oncologist who wants to see what growth there is over the next three weeks.  What concerned me is that the Dr said there are no other options to Keytruda, so if it's not working that's basically it - other than "studies". 

Is Keytruda the only currently approved treatment in Canada?  I've read here about other treatments like opdivo, ipi/nivo, taf/mek etc and understand the side effects can be difficult. She's tolerating the Keytruda well. Any thoughts on what I should ask for if they decide the tumour is back and Keytruda isn't working? Two small satellites appeared then disappeared within a couple of weeks, so I'm hoping that's a good sign. They won't redo the CT scan for another two months. Isn't it too soon to decide whether it's working, even if the tumour is growing? She is Braf positive. Thank you.

Part A - Skin excision right calcaneous:
- Invasive melanoma
- Anatomical level: 5
- Vertical thickness: approximately 7.0 mm
- Ulcerated
- Mitotic rate: 7/mm. squared
- Perineural and lymphovascular space invasion: present
- Completely excised

Procedure: Excision Tumour
Tumour Site: Skin of lower limb and hip -
Tumour Size: 45.0 Millimeters (mm)
Histologic Type: Melanoma, not otherwise classified
Tumour Extent
Macroscopic Satellite Nodule(s): Not identified
Ulceration: Present
Vertical Height (mm): 7.0 Millimeters (mm)
Mitotic Rate: 7 mitoses / mm2

Accessory Findings
Microsatellite(s): Not identified
Lymph-Vascular Invasion: Present
Neurotropism: Present
Tumour Regression: Not identified
Peripheral Margins: Uninvolved by invasive melanoma
Distance of Invasive Melanoma from Closest Peripheral
Margin: Cannot be determined - .
Status of Melanoma In Situ at Peripheral Margins:
Uninvolved by melanoma in situ
Distance of Melanoma In Situ From Closest Peripheral
Margin: Cannot be determined - .
Deep Margin: Uninvolved by invasive melanoma
Distance of Invasive Melanoma from Deep Margin: 4.8
Millimeters (mm)
Regional Lymph Nodes: No lymph nodes submitted or found
Pathologic Stage Classification (pTNM, AJCC 8th Edition)
Primary Tumour (pT): pT4b
Regional Lymph Nodes (pN): pNX


FDG avid lymph nodes in right inguinal region and along right external iliac chain. Largest node is right inguinal measuring 28 x 18 mm, SUV max 9.6. Additionally there is an FDG avid lymph node right ileocolic distribution measuring 17 x 13 mm, SUV max 6.3. FDG avid node posterior to the inferior vena cava, SUV max 3.5. This node is small, measuring 5 x 8 mm on CT.


Anonymous - (5/15/2018 - 10:03am)

Sorry you are going through this. It is my understanding that treatment depends on provincial standards. 

Anonymous - (5/15/2018 - 10:10am)

If you do a google search of your province and Melanoma Standard of care. You should be able to locate the provincial DoH guidelines for treatment. Unfortunately Canada is not at the same level as US in treatment. 

Anonymous - (5/15/2018 - 11:52am)

Actually I found a better source for you. Go to CADTH.CA. It listed the drugs as well as whether they are funded by the province. Nivo as of  April 2017 is funded in all but pei where it was under review. 


Best of luck

Thank you for the info. I've gone through all the options - seems like there may be a something if she has the BRAF V600 positive mutation.  Will have to ask.

This is another Canadian defence that shows what is covered in various provinces.   If you have private insurance, they might cover things that aren’t covered provincially


Thank you - I think there are some possible options. Unfortunately she doesn't have private insurance.