Chemotherapy of malignant melanoma

The evolution in melanoma treatment as a reflection of precision-oriented medicine

Until recently, metastatic melanoma was a disease with limited treatment options and a poor prognosis. Dacarbazine was accepted as the standard treatment for melanoma in the 1970s, and despite inducing an overall survival of approximately 7.4 months, it remained so until relatively recently. In the last few years, significant advances in the molecular understanding of this disease have facilitated the development of novel and promising drugs. Precision-oriented medicine is currently revolutionizing the practice of oncology. Targeted therapies have demonstrated great potential in treating melanoma and various other types of cancer, including breast, colorectal and non-small cell lung cancer. Here, we review the evolution of melanoma treatment from single-agent chemotherapy to combination therapy, the emergence of immunotherapy in melanoma and the development of targeted therapies, such as the use of the BRAF inhibitor as a treatment agent. The ability to treat melanoma according to the fingerprint of the tumor reflects an overall change in the practice of oncology.

Phase II evaluation of dibromodulcitol and actinomycin D, hydroxyurea, and cyclophosphamide in previously untreated patients with malignant melanoma

In this Eastern Cooperative Oncology Group (ECOG) phase II study, dibromodulcitol (DBD) and a combination of actinomycin D, hydroxyurea, and cyclophosphamide (AHC) were compared with methyl-CCNU, the current ECOG standard, in patients who had received no prior chemotherapy for disseminated malignant melanoma. The response rates were 6% (3/50) for AHC, 9% (3/34) for DBD, and 14% (7/49) for methyl-CCNU. Median survival times were 4, 5, and 6 months, respectively. Neither regimen appears to offer any advantage over methyl-CCNU as front-line therapy for patients with disseminated melanoma.

Dosimetry of cytostatics in hyperthermic regional isolated perfusion

During the period from February to October 1983, 21 patients with malignant melanoma of the extremities were treated by hyperthermic regional isolated perfusion with L-phenylalanine mustard (melphalan). The melphalan dose for each patient was determined by the tissue volume of the perfused region, using a dose of 10 mg/l perfused tissue. Despite an average increase of melphalan dosage of 18% above the maximum for iliac perfusions recommended in the literature, no increase in toxic tissue reactions was observed after hyperthermic iliac perfusions. The same dose of 10 mg/l perfused tissue was used in hyperthermic axillary perfusions, resulting in an average decrease of melphalan dosage of 14% below the minimum recommended in the literature. By applying a constant dose per unit tissue volume, a standardization of treatment is achieved. This excludes variations like body weight, age, type of complexion, and hair color, which so far have determined dosimetry.

Detection of melanoma cells in bone marrow using monoclonal antibodies. A comparison of fluorescence activated cell sorting (FACS) and conventional immunofluorescence (IF)

Seven different human melanoma cell lines have been tested for the presence of melanoma associated antigen p97. The sensitivity of membrane immunofluorescence assays for the antigen was increased by using a mixture of antibodies to several epitopes of p97. Six of eight melanoma lines were strongly positive. Normal bone marrow was negative. When cultured p97-positive melanoma cells were added to normal marrow, the authors were able to detect 5% contamination, by fluorescence-activated cell sorting (FACS) and immunofluorescence (IF). No melanoma cells were found in one fresh and nine frozen bone marrow specimens of melanoma patients (including two with known positive marrow by routine histologic study) evaluated for autologous bone marrow transplantation after high-dose chemotherapy.

The natural history of resectable metastatic melanoma (Stage IVA melanoma)

One-hundred-two patients with malignant melanoma who had distant metastases surgically resected and were judged to be clinically free of disease (M. D. Anderson Stage IVA melanoma) were studied. The median survival for all the patients from time of diagnosis of stage IVA disease was 18 months. The site of the resected metastases did not appear to influence survival, being approximately the same for the brain (15 months), lung (16 months), intraabdominal (18 months), and skin and/or lymph nodes (23 months). The site of the resected metastases also did not influence the median disease-free interval. Patients who had metastases resected from several organs at the same time had a median survival of 15 months, which was similar to that of patients with one resected site. Patients who were rendered Stage IVA on several occasions by surgical excisions had a median survival of 36 months. Thirty-five patients received surgery only and 67 patients received adjuvant chemotherapy, immunotherapy, or combined chemoimmunotherapy after surgery. For the group treated with surgery only, the median disease-free interval and survival from diagnosis of stage IVA disease were 6 months and 16 months, respectively, and for the adjuvant group 6 months and 21 months, respectively. Specifically, by the type of adjuvant therapy, the median disease-free interval and survival from stage IVA for 23 patients receiving Corynebacterium parvum were 6.9 and 19 months; for 39 patients receiving BCG, eight months and 26 months; for 24 patients receiving BCG + DTIC, eight and 17.4 months; and for all 51 DTIC treated patients 6.3 and 17.8 months, respectively. Patients receiving BCG had a median survival superior to the surgery only group (P = 0.02). An increase in survival was seen predominantly in patients who achieved IVA status more than once and received BCG. Patients with recurrent soft-tissue metastases appeared to benefit most from BCG in prolonging the disease-free interval. Only 1/10 treated by surgery alone had a disease-free interval longer than 1 year, compared with 9/16 who received BCG (P = 0.01). Stage IVA melanoma appears to be distinctly different in prognosis from Stage IVB melanoma and should be classified separately. Patients with recurrent soft-tissue disease may benefit significantly from treatment with BCG.

The surgical management of anorectal malignant melanoma

The biological vagaries of anal malignant melanoma are illustrated by four cases in Chinese patients. All four died within five years. Their poor prognosis emphasizes the value of preoperative studies to detect clinically occult metastases and obviate futile radical surgery. Many patients already have disseminated disease at the time of diagnosis, and local excision of the tumour provides acceptable palliation. For localized disease, abdominoperineal resection prevents local recurrence and removes the mesenteric nodes which are frequently involved. Palpable inguinal nodes necessitate therapeutic groin dissection, but we perform elective resection only when affected nodes are found at laparotomy. Pelvic lymphadenectomy should be performed in conjunction with abdominoperineal resection. The efficacy of chemotherapy for anorectal melanoma remains uncertain.