dermatologic disorders
Melanoma
Treatment of Melanoma
Surgical excision Possibly adjuvant radiation therapy,imiquimod, or cryotherapy For metastatic or unresectable melanoma, immunotherapy (eg,pembrolizumab,nivolumab,ipilimumab), targeted therapy (eg,vemurafenib,dabrafenib,encorafenib), and radiation therapy (See also the American Academy of Dermatology Association’s2019 guidelines of care for the management of primary cutaneous melanoma.) Treatment of melanoma is primarily by surgical excision (wide local excision). Although the width of margins is debated, most experts agree that a 1-cm lateral tumor-free margin is adequate for lesions<0.8 mm thick. In tumors < 0.8 mm thick but with ulceration, sentinel lymph node biopsy can be considered. Thicker lesions may deserve larger margins, more radical surgery, and sentinel lymph node biopsy. Lentigo maligna melanoma and lentigo maligna are usually treated with wide local excision and, if necessary, skin grafting. Intensive radiation therapy is much less effective. The ideal treatment of melanoma in situ is surgical excision. Sometimes this can be accomplished with staged excisions or Mohs micrographic surgery, in which tissue borders are progressively excised until specimens are tumor-free (as determined by microscopic examination during surgery). If patients decline or are not candidates for surgical therapy (eg, because of comorbidities or involvement of cosmetically important areas),imiquimodand cryotherapy can be considered. Most other treatment methods usually do not penetrate deeply enough into involved follicles, which must be removed. Spreading or nodular melanomas have usually been treated with wide local excision. Lymph node dissection is recommended when nodes are involved clinically or on histologic evaluation of sentinel lymph node biopsy. Treatment of metastatic melanoma typically includes Immunotherapy Molecular targeted therapy Radiation therapy Rarely surgical resection All of these treatments should be considered for all patients who have metastatic melanoma. Final decisions are generally individualized by an oncologist and may depend on availability. Metastatic disease is generally inoperable, but in certain cases, localized and regional metastases can be excised to help eliminate residual disease and prolong survival. Immunotherapy of Cancer None Ipilimumab(a monoclonal antibody to cytotoxic T lymphocyte-associated antigen 4 [CTLA-4]) is another form of immunotherapy that can also lengthen survival. It works by preventing anergy of T cells, thus freeing the immune system to attack tumor cells. The combination PD-1 and CTLA-4 inhibitor (nivolumab/ipilimumab) is preferred, but a combination PD-1 and LAG-3 inhibitor (nivolumab/relatlimab) is also available. ) are available for patients who are ineligible for immunotherapy ( Treatment references , Cytotoxic chemotherapy has not been shown to improve survival in patients with metastatic disease and is normally reserved for patients who do not have other options. Radiation Therapy for Cancer None The following are under study: Infusion of lymphokine-activated killer cells or antibodies (for advanced-stage disease) Active Specific Immunotherapy None 1.Long GV, Flaherty KT, Stroyakovskiy D, et al:Dabrafenibplustrametinibversusdabrafenibmonotherapy in patients with metastaticBRAFV600E/K-mutant melanoma: Long-term survival and safety analysis of a phase 3 study.Ann Oncol28(7):1631–1639, 2017. doi: 10.1093/annonc/mdx176.Clarification and additional information.Ann Oncol30(11):1848, 2019. 2.Long GV, Stroyakovskiy D, Gogas H, et al:Dabrafenibandtrametinibversusdabrafeniband placebo for Val600 BRAF-mutant melanoma: A multicentre, double-blind, phase 3 randomised controlled trial.Lancet386(9992):444–451, 2015. doi: 10.1016/S0140-6736(15)60898-4 3.Long GV, Stroyakovskiy D, Gogas H, et al: Combined BRAF and MEK inhibition versus BRAF inhibition alone in melanoma.N Engl J Med371(20):1877–1888, 2014. doi: 10.1056/NEJMoa1406037 4.Mendenhall WM, Shaw C, Amdur RJ, et al: Surgery and adjuvant radiotherapy for cutaneous melanoma considered high-risk for local-regional recurrence.Am J Otolaryngol34(4):320–322, 2013. doi: 10.1016/j.amjoto.2012.12.014 5.Rule WG, Allred JB, Pockaj BA, et al: Results of NCCTG N0275 (Alliance): A phase II trial evaluating resection followed by adjuvant radiation therapy for patients with desmoplastic melanoma.Cancer Med5(8):1890–1896, 2016. doi: 10.1002/cam4.783 