Advanced Melanoma

Stage IV melanomas have spread either beyond the regional lymph nodes to the skin or other lymph nodes (for example, spreading to the skin of the abdomen for an initial melanoma on the leg) or to distant organs, such as the liver, lungs or brain. 

Patients with stage IV melanoma should be treated in centres with broad experience in dealing with this disease. Whenever possible, they should be treated in the context of clinical trials. 

The treatment options for patients with stage IV melanoma depend on the number and type of metastases. It is recommended that the decision for treatment is based on discussion in an inter‐disciplinary team of medical professionals. This meeting of different specialists is called multidisciplinary opinion or the tumor board review. In this meeting, the planning of treatment will be discussed according to the relevant information about the patient, about the extent of the cancer and about previous treatments. The written decision of the tumor board must be accessible to the patient. 

Single Metastasis 

A single metastasis may be removed by surgery, especially in the brain, the lung and the liver. This requires that the person is in good health. A single metastasis in the brain can also be treated by a special type of radiotherapy that targets precisely the metastasis to avoid radiation reaching the normal brain tissue around the tumor. This is called stereotactic gamma knife radiosurgery. Depending on the location of the brain metastasis, it can sometimes be preferred over neurosurgery. 

When surgery is not feasible, another option is the use of a combination of chemotherapyand immunotherapy, if possible within a clinical trial. 

Multiple Metastases  

When there are multiple metastases in the body, surgery is rarely possible. Therefore, the goal of the treatment is to target the cancer cells all over the body. This is done with chemotherapy  drugs that can directly kill cancer cells or with immunotherapy drugs that helps the immune system to recognise and destroy cancer cells. 

Surgery 

Removal of the metastases by surgery may be appropriate for some people who are in good health and depending on the location and extent of the metastases, but this treatment is rarely feasible or useful. 

Chemotherapy and Immunotherapy  

The goal of chemotherapy and immunotherapy is to target the cancer cells all over the body. A combination of both, if possible within a clinical trial, is the preferred option. No standard therapy has shown to be better and safer. 

All chemotherapy and immunotherapy drugs have frequent side effects. Some may not be well‐tolerated by some patients. It is recommended to ask doctors about the expected benefits and risks of every treatment in order to be fully informed of the consequences of the treatment. 

Radiotherapy  

External radiotherapy can be used to relieve the symptoms and pain caused by brain or bone metastases . 

New Promising Immunotherapies 

New therapies aiming to help the immune system to fight the cancer have been developed recently, either alone or combined. These therapies are experimental and not all are yet available, except in clinical trials. The main ones are ipilimumab, cancer vaccines and dendritic cell therapy. 

Ipilimumab is an antibody which, once injected, helps the white blood cells to recognize and attack cancer cells. Recent data show that patients with metastatic melanoma treated with ipilimumab lived an average of 4 months longer than patients who received a cancer vaccine. Other types of antibodies are also studied in clinical trials  in the treatment of melanoma. 

Cancer vaccines  contain antigens of the tumor, which are small pieces of proteins coming from tumor cells. Following the injection of the vaccine, certain white blood cells bind to the antigens injected and stimulate the immune response against the tumor cells. 

Dendritic cell therapy is based on the isolation of the patient’s own white blood cells, which are processed in the laboratory and subsequently re‐administered to the patient. The manipulated dendritic cells induce other immune cells in the body to specifically attack the cancer cells.

 


Source: Melanoma: a guide for patients ‐ Information based on ESMO Clinical Practice Guidelines ‐ v.2011.2