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Combined modality therapy of malignant melanoma

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Abstract

The major modalities of therapy, namely, surgery, radiotherapy, chemotherapy, and immunotherapy, are each of value in selected cases of malignant melanoma. However, because none of these therapies, alone, is capable of curing or controlling some subgroups of melanoma patients, combined modality therapy needs to be used more extensively. Surgery is of particular value in the treatment of primary tumors and in recurrent or regional metastatic disease. Chemotherapy for malignant melanoma has been disappointing. The most active single agent, DTIC, induces only about a 20% response rate, and little or no significant improvement is seen when DTIC is combined with other agents. However, chemotherapeutic agents when utilized by isolation perfusion in the treatment of primary or recurrent melanoma of the extremities, in conjunction with surgical excision of the primary tumor, produce cure rates of approximately 85% in patients with stage I disease and 50% in those with stage II disease. Immunotherapy appears to be of significant value in primary melanoma, and intra-lesional BCG immunotherapy of cutaneous or subcutaneous metastatic lesions has yielded a 50% response rate.

Successful combined modality therapy would take into account the natural history and course of the disease. Conventional therapy consists of surgery as primary therapy, followed by chemo- or immunotherapy. Further research is needed to determine if better results can be achieved by altering the sequence of utilization of the various treatment modalities.

Résumé

Dans les mélanomes malins, les principales possibilités thérapeutiques, chirurgie, radiothérapie, chimiothérapie, immunothérapie, ont des indications bien précises. Aucune n'est, à elle seule, capable de guérir ou d'apporter une palliation valable dans tous les sous-groupes de mélanomes. Il faut donc utiliser fréquemment des thérapeutiques combinées. La chirurgie est particuliérement utile pour la tumeur primitive, pour les récidives locales et pour les métastases régionales. Les résultats de la chimiothérapie ne sont guère encourageants. L'agent le plus actif, le DTIC, ne donne que quelques 20% de réponses lorsqu'il est utilisé isolément, et guère mieux lorsqu'il est associé à d'autres drogues. Mais la chimiothérapie par perfusion régionale, lorsqu'elle est combinée à l'excision de la tumeur primitive dans le traitement des mélanomes ou des récidives de mélanomes des membres, donne près de 85% de guérisons pour les malades au stade I et 50% pour les stades II. L'immunothérapie parait efficace pour la tumeur primitive et l'injection intralésionnelle de BCG dans les métastases cutanées ou sous-cutanées donne 50% de réponses favorables.

Pour être efficaces, les thérapeutiques combinées devraient tenir compte de l'histoire naturelle et de l'évolution de la maladie. Le traitement classique est basé sur la chirurgie, suivie de chimio-ou d'immunothérapie. Mais on obtiendrait peut-être de meilleurs résultats en modifiant la séquence des modalités thérapeutiques. Des recherches devraient être poursuivies dans ce sens.

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  1. Departments of Developmental Therapeutics and Surgery, University of Texas System Cancer Center, M.D. Anderson Hospital and Tumor Institute at Houston, Houston, Texas, USA

    Evan M. Hersh M.D., Jordan U. Gutterman M.D. & Charles M. McBride M.D.

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  1. Evan M. Hersh M.D.
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  2. Jordan U. Gutterman M.D.
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Supported by Grant CA 05831 and Contract N01 CB 33888 from the National Cancer Institute.

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Hersh, E.M., Gutterman, J.U. & McBride, C.M. Combined modality therapy of malignant melanoma. World J. Surg. 3, 329–339 (1979). https://doi.org/10.1007/BF01556586

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