What are the recommendations for combined treatments of advanced or metastatic melanoma?

Updated: May 05, 2020
  • Author: Winston W Tan, MD, FACP; Chief Editor: Dirk M Elston, MD  more...
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Combination treatment provides better response and control of the disease and is often used in patients with advanced or metastatic disease who clinically are able to tolerate this approach. Considerations are as follows:

  • Treatment depends on whether melanoma is limited (resectable) or disseminated (unresectable)

  • For limited disease, resection is recommended, followed by nivolumab [5]

  • Other options for treatment for limited disease includes clinical trial or systemic therapy with interleukin-2 (IL-2) or temozolomide, dacarbazine for two to three cycles, ipilumimab q3wk four times, and then assessment for response; if stable, continue treatment (see below for drug regimens)

Stage IV with diffuse metastasis:

For patients who have unresectable or metastatic melanoma with BRAF V600E or V600K mutation:

Other approaches are as follows:

  • For patients with unresectable disease without brain metastases, treatment includes systemic therapy patients with brain metastases require treatment of the central nervous system disease
  • For stage IV disease in one limb, recommendations include surgery plus  lymph perfusion treatment plus options such as observation, clinical trial, or treatment with interferon alfa

For previously untreated patients with BRAF V600 wild-type, unresectable or metastatic melanoma:

  • Nivolumab 1 mg/kg IV over 30 min followed by ipilimumab 3 mg/kg IV over 90 min administered on the same day q3wk for 4 doses; subsequent single-agent nivolumab doses are 240 mg q2wk or 480 mg q4wk over 30 min until disease progression or unacceptable toxicity [12, 13] or

  • Dacarbazine 220 mg/m2 IV on days 1-3 plus carmustine 150 mg/m2 IV on day 1 plus cisplatin 25 mg/m2 IV on days 1-3; repeat cycle with dacarbazine and cisplatin q21 days; repeat cycle of carmustine q42days or

  • Interferon alfa-2b (15 million IU/m2 IV on days 1-5, 8-12, and 15-19 as induction therapy or  10 million IU/m2 SC 3 times weekly after induction therapy) plus  dacarbazine 200 mg/m2 IV on days 22-26

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