Metastasectomy Metastatic Melanoma

  • Despite recent advances in systemic therapy for advanced melanoma:
    • This disease will eventually fail to respond to systemic therapies in the majority of patients with stage IV disease:
      • And surgical resection (metastasectomy) thus remains an important consideration
    • The findings of retrospective series and prospective registries:
      • Have confirmed that long-term survival is possible for a substantial minority of appropriately selected patients who have resection for stage IV disease
    • With appropriate patient selection, metastasectomy:
      • May be the initial preferred modality rather than systemic therapy
    • A history of significant autoimmune disease, such as colitis:
      • Could exclude a patient from consideration of checkpoint blockade drugs:
        • However, metastasectomy would be a reasonable consideration even in patients who are candidates for systemic treatment
  • Appropriate selection of candidates for metastasectomy is crucial:
    • Although solitary metastases are most favorable:
      • The presence of more than one nodule is not an absolute contraindication to resection
      • Selection factors include:
        • The extent of disease:
          • The number of metastases
          • The number of involved sites
        • The tumor growth rate or doubling time
        • The patient’s comorbidities
        • It must be possible to remove all evident disease:
          • As incomplete resection of metastases has not been beneficial in some patients relative to nonsurgical treatment
        • Palliative intent is another potential indication for surgery in stage IV melanoma:
          • But this is not the only indication for surgery
  • References:
    • Chapman PB, Hauschild A, Robert C, et al. Improved survival with vemurafenib in melanoma with BRAF V600E mutation. N Engl J Med. 2011;364:2507-2616.
    • Morton DL, Foshag LJ, Hoon DS, et al. Prolongation of survival in metastatic melanoma after active specific immunotherapy with a new polyvalent melanoma vaccine. Ann Surg. 1992;216:463-482.
    • Ollila DW. Complete metastasectomy in patients with stage IV metastatic melanoma. Lancet Oncol. 2006;7:919-924.
    • Sosman JA, Moon J, Tuthill RJ, et al. A phase 2 trial of complete resection for stage IV melanoma: Results of Southwest Oncology Group Clinical Trial S9430. Cancer. 2011;117:4740-4746.

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