Clinical results using biochemotherapy as a standard of care in advanced melanoma

Optimal management of metastatic melanoma: current strategies and future directions

Melanoma is increasing in incidence and remains a major public health threat. Although the disease may be curable when identified early, advanced melanoma is characterized by widespread metastatic disease and a median survival of less than 10 months. In recent years, however, major advances in our understanding of the molecular nature of melanoma and the interaction of melanoma cells with the immune system have resulted in several new therapeutic strategies that are showing significant clinical benefit. Current therapeutic approaches include surgical resection of metastatic disease, chemotherapy, immunotherapy, and targeted therapy. Dacarbazine, interleukin-2, ipilimumab, and vemurafenib are now approved for the treatment of advanced melanoma. In addition, new combination chemotherapy regimens, monoclonal antibodies blocking the programmed death-1 (PD-1)/PD-ligand 1 pathway, and targeted therapy against CKIT, mitogen-activated protein/extracellular signal-regulated kinase (MEK), and other putative signaling pathways in melanoma are beginning to show promise in early-phase clinical trials. Further research on these modalities alone and in combination will likely be the focus of future clinical investigation and may impact the outcomes for patients with advanced melanoma.

Immunotherapy of Melanoma

Melanoma has been widely studied as a target for immunotherapy because it has been considered more susceptible to immune attack than other tumors and because of the relative ease with which melanoma cells can be adapted to in vitro culture. The availability of hundreds of melanoma cell lines for study has led to the identification of tumor antigens and the development of monoclonal antibodies and T cells against these antigens, revolutionizing the understanding of how the immune system sees and reacts to cancer. This article reviews the recent clinical results of trials exploring different immunotherapy strategies against melanoma.

Melanoma treatment update

Except for high-dose interferon as adjuvant therapy in stage III disease, little success has emerged over the last 20 years for metastatic melanoma. Recent advances in melanoma biology suggest that disarming oncogenic mechanisms in melanoma may be an attractive approach to therapy. For instance, sustained expression of Bcl2 has been associated with an increased resistance to apoptosis, and recently, anti-sense-mediated reduction of Bcl2 levels was shown to chemosensitize patients to dacarbazine, dimethyl triazino imidazole carboxomide, or DTIC. Likewise, the identification of activating mutations in the RAS signaling pathway, including the NRAS and BRAF genes, opens up new therapeutic options for RAS and RAF inhibitors. A more thorough understanding of melanoma biology and tumor immunology will undoubtedly yield new promise for patients with advanced disease.

Role of the Head and Neck Surgeon in Sentinel Lymph Node Biopsy for Cutaneous Head and Neck Melanoma

OBJECTIVE

To determine the reliability of sentinel lymph node biopsy (SLNB) in head and neck cutaneous melanomas to accurately stage nodal basins, describe techniques for safe SLNB in the neck and parotid regions, and discuss treatments.

STUDY DESIGN

Retrospective chart review with follow-up mean of 11 months.

METHODS

The charts of 80 patients treated for head and neck cutaneous malignancies from January 2001 through June 2003 were reviewed for presentation, treatment, and outcome.

RESULTS

All patients received lymphoscintigraphy and SLNB for melanoma with Breslow thickness greater than 1 mm. Accurate preoperative lymphoscintigraphy and blue dye injection along with facial nerve monitoring when indicated correlated with safe SLNB. Eleven (14%) patients required completion surgery after positive SLNB and underwent evaluation for adjuvant therapies. There were three cases with complications: two postoperative hematomas and one seroma.

CONCLUSIONS

Safe and reliable SLNB depends on the knowledge of the anatomy in the head and neck region, reliability of preoperative lymph node mapping with lymphoscintigraphy, and possible additions of blue dye injection and facial nerve monitoring. Complete surgical treatment of positive SLNB cases along with adjuvant therapies potentially improves control of these cutaneous malignancies with manageable morbidity.