[Locally recurrent and metastatic malignant melanoma. Long-term results and prognostic factors after percutaneous radiotherapy]

Treatment of melanoma

INTRODUCTION

The incidence of melanoma has increased fivefold during the past three decades. Melanoma can no longer be classified as rare; rather, it is now one of the more frequent tumors.

METHODS

Recommendations for the diagnosis and treatment of melanoma are laid out in the interdisciplinary S2 guidelines of the German Cancer Society, upon which the present review is based. The goal of this article is to present the clinical core recommendations for treatment in all disease stages.

RESULTS

The operative management of primary melanoma usually takes place in two steps. A complete excisional biopsy with a safety margin of about 2 mm is performed in order to establish the histopathological diagnosis. Definitive surgical excision is performed with a safety margin of 1 cm in tumors up to 2 mm thick, 2 cm in thicker tumors. In tumors more than 1 mm thick, sentinel lymph node biopsy should be performed to aid in tumor staging. Radiotherapy is indicated in inoperable tumors of all stages. Adjuvant immunotherapy with interferon alpha is recommended in tumors of thickness >2 mm and in locoregional metastasis. If distant metastasis is present and R0 surgery is not an option, the treatment should primarily comprise monochemotherapy or alternatively the patient should be enrolled in a clinical trial.

CONCLUSION

The recommendations presented here are based predominantly on the results of prospective randomized trials.

[Malignant melanoma. Diagnosis and therapy]

In Germany, 6100 women and 5300 men contract a malignant melanoma of the skin every year. The chances of being cured are good in the early stages of the disease, but the average survival following distant metastasis is only 6 to 9 months. Therefore, early diagnosis is crucial, particularly as the skin is, by nature, a readily accessible organ. The introduction of epiluminescence microscopy has increased diagnostic accuracy significantly. In cases of doubt, complete excision of the suspect pigmented lesion is always advisable. A light skin type, presence of numerous naevi, genetic predisposition (familial history) and increased UV exposure are considered as risk factors. As a rule, adjuvant imunotherapy with interferon-alphais recommended in high-risk patients. A multidisciplinary approach consisting of surgery, radiotherapy, chemotherapy and immunotherapy has proved beneficial in advanced stages of metastasis.

[Therapy of malignant melanoma at the stage of distant metastasis]

Treatment of melanoma in the stage of distant metastasis aims on palliation and achievement of durable tumor remission with prolongation of survival. As long as metastasis is confined to one organ system and is removable, surgery remains the treatment of first choice. In limited metastasis radiotherapy may likewise be indicated, particularly in bone and brain metastasis. More extensive metastasis should be treated by chemotherapy or chemoimmunotherapy. Monochemotherapy with dacarbazine, temozolomide, fotemustine and vindesine or its combinations with interferon-alpha are currently preferred. Polychemotherapy or its combinations with interferon-alpha and interleukin-2 are suitable to produce higher response rates but failed to prolong survival. As these treatments are associated with substantially higher toxicity they have been widely abandoned. Combined treatment with dacarbazine and interferon-alpha obtain tumor responses or stable disease in 40-50% and objective tumor remissions in 15-20% of patients. Effective cancer vaccination strategies and blockade of melanoma specific target molecules are currently developed as new treatment options.