METASTATIC MELANOMA

By Gary M. White, MD

Metastatic Melanoma


Metastatic melanoma is melanoma that has spread to other parts of the body.

Clinical

Metastatic (or recurrent) melanoma may manifest itself in many ways including:

Thus, high clinical suspicion is in order when following up on a patient with a history of melanoma. An examination and palpation of the melanoma scar, palpation of lymph nodes, complete skin exam, inquiry as to overall health and new symptoms of any kind, etc., should all be done.

Dermal Melanoma?

If a solitary lesion is biopsied and there is a melanoma in the dermis without an epidermal component, consider the following:

Treatment

Various drugs have recently been approved for the treatment of metastatic melanoma. These new drugs have revolutionized the treatment of melanoma and enhanced prognosis for patients [JAAD 2017;77;356].

BRAF Inhibitors

Dabrafenib and Trametinib

BRAF inhibitors. The FDA has approved dabrafenib (Tafinlar) and trametinib (Mekinist) separately and in combination for the treatment of advanced (metastatic) or unresectable melanoma in patients with specific BRAF mutations.

Vemurafenib

The BRAF inhibitor Vemurafenib (Zelboraf) is FDA-approved for patients with late-stage or unresectable melanoma who test positive for the BRAF V600E mutation.

Non-BRAF Inhibitors

Ipilimumab

Ipilimumab (Yervoy) is FDA-approved for the treatment of melanoma. It increases overall survival in Stage III melanoma at 5 years. (65 vs 54% at 5 years). Long term cure from ipilimumab is on the order of 22%. It is a monoclonal antibody that activates the immune system by targeting CTLA-4, a protein receptor that down-regulates the immune system. Many side effects may occur including colitis, diarrhea, rash etc. Ipilimumab has been reported to cause dermatomyositis [JAMA Derm 2015;151;195] and occasionally death.

Nivolumab

Nivolumab (Opdivo) is an anti-PD-1 medication. The FDA has approved it for patients with unresectable or metastatic melanoma and disease progression after treatment with ipilimumab (Yervoy) and for patients whose tumors are BRAF V600 mutation positive, a BRAF inhibitor. A drug rash from nivolumab is seen here.

Pembrolizumab

Pembrolizumab (Keytruda), which belongs to a new class of immunotherapies that work by blocking a pathway in the immune system known as PD-1.

Peginterferon alfa-2b

Cutaneous Metastatic Melanoma

In-transit cutaneous melanoma metastases are usually treated with surgical excision with or without local radiation.

11 patients with cutaneous metastatic melanoma experienced a 100% complete local response rate with intaralesional interleukin-2, imiquimod and a topical retinoid [JAAD 2015;73;645].

Additional Pictures

Photograph courtesy of University of California, San Diego
Metastatic Melanoma

Prominent supraclavicular lymphadenopathy from melanoma.
Melanoma Metastatic to a lymph node

Both red and blue/black papules representing metastatic melanoma occurring about the surgical site.
Metastatic Melanoma Metastatic Melanoma Metastatic Melanoma

References

Primary melanoma and metastatic lesions. JAAD January 2010 Volume 62, Issue 1, Page e1

Diffuse hyperpigmentation and melanuria. JAAD March 2013 Volume 68, Issue 3, Pages 482–488

Melanoma and melanuria. JAAD October 2010 Volume 63, Issue 4, Pages e81–e82


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