Practice Therapeutics

Novel therapies for unresectable and metastatic melanoma

BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5174 (Published 30 November 2017) Cite this as: BMJ 2017;359:j5174
  1. Chante Karimkhani, dermatology resident1,
  2. Bobby Y Reddy, instructor in dermatology2,
  3. Robert P Dellavalle, chief of dermatology1 3 4,
  4. Srinath Sundararajan, assistant professor of medicine5
  1. 1Department of Dermatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
  2. 2Wellman Center for Photomedicine, Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
  3. 3Dermatology Service, Eastern Colorado Health Care System, US Department of Veteran Affairs, Denver, CO, USA
  4. 4Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
  5. 5Division of Hematology and Oncology, Department of Medicine, University of Arizona, Tucson, AZ, USA
  1. Correspondence to: Chante Karimkhani ck2525{at}caa.columbia.edu

What you need to know

  • Immunotherapy and targeted therapy against mutations of BRAF gene are newer treatments for advanced (unresectable or metastatic) melanoma

  • These treatments have shown better response and survival rates than chemotherapy in advanced melanoma, but evidence on long term benefit is lacking

  • Refer any patient with recurrence of melanoma, change in size or appearance of lesions, or symptoms suggestive of spread of disease to specialist cancer physicians for staging the disease, genetic analysis, and planning the appropriate treatment

A 60 year old white woman who had a melanoma excised a year ago now presents with multiple subcutaneous nodules along her left shin. Biopsy confirms the lesions as metastatic melanoma, with molecular analysis revealing a BRAF wild type genotype. Imaging also shows several small nodules throughout her lungs. The patient is recommended to start systemic treatment with immunotherapy.

About 132 000 cases of melanoma are diagnosed globally every year.12 Surgical excision is the first line treatment for localised disease.3 A minority of patients present with increased tumour growth or ulceration, or with metastasis (see box 1). The prognosis varies by stage at diagnosis. Data from the United States show five year survival rates of 98% for local disease confined to site of origin, 63% for regional metastases with spread to surrounding lymph nodes or tissues, and 17% for distant metastases.6 Systemic chemotherapy with drugs such as dacarbazine has shown limited benefits in patients with metastatic melanoma, with median survival between six and 10 months.789 Over the past decade, understanding of molecular biology and immune regulation in melanoma has led to advancements in the treatment of unresectable and metastatic melanoma.

Box 1: Definitions of terms45

  • Unresectable melanoma—Melanoma that is very large or has significantly spread to local lymph nodes or lymphatic tracts and is thus deemed to be unresectable by the surgeon …

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