Cutaneous Melanoma Medication

  • Author: Susan M Swetter, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Feb 23, 2012
 

Medication Summary

High-dose IFN alfa-2b is the only adjuvant therapy approved by the US Food and Drug Administration for high-risk resected melanoma, defined as deep primaries greater than 4 mm in Breslow depth (AJCC stage IIB) and regional lymph node metastasis (stage III). Various trials of low-dose IFN have shown no benefit in disease-free relapse or OS rates.[86] Similarly, multiple melanoma vaccine trials are in progress, predominantly for stage III and IV disease, but they have not demonstrated an OS advantage to date.

Ipilimumab, a CTLA-4 blocker approved by the FDA March 25, 2011, enhances the T-cell response in HLA2-positive patients and demonstrates remarkable promise in patients with metastatic melanoma. It is being studied by itself and in combination with other immunotherapies and vaccines.[87, 88]

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Immunomodulatory Agents

Class Summary

Enhance host immunity for cancer surveillance and eradication.

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Interferon alfa-2b (Intron A)

 

Protein product manufactured by recombinant DNA technology. Produced naturally by cells in the body to combat infections and tumors. Mechanism of antitumor activity is not clearly understood; however, direct antiproliferative effects against malignant cells and modulation of host immune response may play important roles.

Generally initiated within 56 d of surgery and typically administered by medical oncologists.

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Monoclonal Antibodies

Class Summary

Considered second-line treatment for unresectable or metastatic melanoma.

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Ipilimumab (Yervoy)

 

Targeted T-cell antibody. Recombinant, human cytotoxic T-lymphocyte antigen 4 (CTLA-4)–blocking antibody indicated for unresectable or metastatic melanoma. CTLA-4 is a negative regulator of T-cell activation. Ipilimumab binds to CTLA-4 and blocks the interaction of CTLA-4 with its ligands, CD80/CD86. Blockade of CTLA-4 has been shown to augment T-cell activation and proliferation. Proposed mechanism of action is indirect, possibly through T-cell–mediated antitumor immune responses.

IgG1 kappa immunoglobulin with an approximate molecular weight of 148 kd. Produced in mammalian (Chinese hamster ovary) cell culture.

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BRAF Inhibitors

Class Summary

Some mutations in the BRAF gene including V600E result in constitutively activated BRAF proteins, which can cause cell proliferation in the absence of growth factors that would normally be required for proliferation.

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Vemurafenib (Zelboraf)

 

BRAF inhibitor indicated for unresectable or metastatic melanoma with BRAF-V600 mutation as detected by an FDA-approved test. Not recommended for use with wild-type BRAF melanoma.

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Contributor Information and Disclosures
Author

Susan M Swetter, MD  Director, Pigmented Lesion and Melanoma Program, Professor, Department of Dermatology, Stanford University Medical Center and Cancer Institute, Veterans Affairs Palo Alto Health Care System

Susan M Swetter, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, American Society of Clinical Oncology, Eastern Cooperative Oncology Group, Pacific Dermatologic Association, Society for Investigative Dermatology, Society for Melanoma Research, and Women's Dermatologic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Günter Burg, MD  Professor and Chairman Emeritus, Department of Dermatology, University of Zürich School of Medicine; Delegate of The Foundation for Modern Teaching and Learning in Medicine Faculty of Medicine, University of Zürich, Switzerland

Günter Burg, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, International Society for Dermatologic Surgery, North American Clinical Dermatologic Society, and Pacific Dermatologic Association

Disclosure: Nothing to disclose.

Michael J Wells, MD  Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

John G Albertini, MD  Consulting Staff, Dermatologic Surgery, The Skin Surgery Center; Program Director, ACGME Accredited Fellowship in Procedural Dermatology

John G Albertini, MD is a member of the following medical societies: American Academy of Dermatology and American College of Mohs Micrographic Surgery and Cutaneous Oncology

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

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Superficial spreading melanoma, left breast, 1.3-mm Breslow depth.
Lentigo maligna melanoma, right lower cheek. Centrally located erythematous papule represents invasive melanoma with surrounding macular lentigo maligna (melanoma in situ).
Acral lentiginous melanoma (1-mm Breslow depth), left sole. Diagnostic punch biopsy site is located superiorly.
Malignant melanoma. Courtesy of Hon Pak, MD.
Cutaneous melanoma with characteristic asymmetry, irregular borders, and color variation. Courtesy of Wendy Brick, MD.
Table. AJCC 2002 Revised Melanoma Staging
StageTNM ClassificationHistologic/Clinical Features5-Year Survival Rate, %
0Tis N0 M0Intraepithelial/in situ melanoma100
IAT1a N0 M0≤1 mm without ulceration and mitotic rate < 1/mm297
IBT1b N0 M0



T2a N0 M0



≤1 mm with ulceration or mitotic rate ≥1/mm2



1.01-2 mm without ulceration



91-94
IIAT2b N0 M0



T3a N0 M0



1.01-2 mm with ulceration



2.01-4 mm without ulceration



79-82
IIBT3b N0 M0



T4a N0 M0



2.01-4 mm with ulceration



4 mm without ulceration



68-71
IICT4b N0 M0>4 mm with ulceration53
IIIAT1-4a N1a M0



T1-4a N2a M0



Single regional nodal micrometastasis, nonulcerated primary



2-3 microscopic positive regional nodes, nonulcerated primary



78
IIIBT1-4b N1a M0



T1-4b N2a M0



T1-4a N1b M0



T1-4a N2b M0



T1-4a/b N2c M0



Single regional nodal micrometastasis, ulcerated primary



2-3 microscopic regional nodes, nonulcerated primary



Single regional nodal macrometastasis, nonulcerated primary



2-3 macroscopic regional nodes, no ulceration of primary



In-transit met(s)* and/or satellite lesion(s) without metastatic lymph nodes



54-59
IIICT1-4b N2a M0



T1-4b N2b M0



Any T N3 M0



Single macroscopic regional node, ulcerated primary



2-3 macroscopic metastatic regional nodes, ulcerated primary



4 or more metastatic nodes, matted nodes/gross extracapsular extension, or in-transit met(s)/satellite lesion(s) and metastatic nodes



40
IVAny T any N M1a



Any T any N M1b



Any T any N M1c



Distant skin, subcutaneous, or nodal mets with normal LDH levels



Lung mets with normal LDH



All other visceral mets with normal LDH or any distant mets with elevated LDH



< 20
*Met is metastasis.
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