How is malignant melanoma treated? Surgery - surgery and drugs

Treatment of primary melanoma

The main method of treatment for primary melanoma is surgical removal. This procedure is only effective when melanoma is detected early. At the time it is unable to metastasize.

As primary melanoma becomes more advanced, its aggressiveness and risk of metastasizing increases.

The tumor must be removed with a sufficiently wide margin of healthy tissue. Some tumor locations (face, palms, flanks) do not allow radical removal. In such cases, it is recommended to maintain a margin of at least 10 mm wide.

Surgical removal of melanomas is carried out at specialised centres. In high-risk melanoma types, the sentinel lymph node is removed at the same time.

If metastatic cells are found in this lymph node, all lymph nodes in the catchment area must be removed.

The risk type of melanoma has the following characteristics:

• Breslow from 1 mm, ev. 0.75-1 mm
• presence of ulceration
• higher number of mitoses
• patient younger than 40 years

Accurate assessment of the primary melanoma and sentinel node is essential for accurate staging of the disease. It allows physicians to determine prognosis and subsequent treatment.

Adjuvant treatment is recommended for malignant melanomas with a high risk of further progression.

Adjuvant treatment

In practice, up to 90 % of all metastases occur five years after surgery for primary melanoma. Approximately 10 % occur after a longer period of time. Sometimes metastases can occur after 30 years.

The aim of adjuvant treatment is to prevent such disease progression.

In the past, adjuvant treatment has used a number of methods, such as chemotherapy, radiotherapy, non-specific immunotherapy and others. Since the 1980s, adjuvant administration of interferon alpha has been widely used.

Methods of adjuvant treatment include:

• Adjuvant actinotherapy - Used in cases where we cannot remove the tumor radically enough (ENT and urogenital areas).
• Adjuvant chemotherapy
• Adjuvant immunotherapy - This is the most widely used method of treatment for advanced primary tumours.

Adjuvant treatment with interferon

Interferons belong to a group of glycoproteins with a broad spectrum of effects:

• immunomodulatory
• antiviral
• antiproliferative
• proproliferative
• antiangiogenic

Various mechanisms are used in the context of melanoma treatment:

• stimulation of macrophage phagocytosis
• increased expression of tumour antigens
• direct cytotoxic effect
• inhibition of tumour cell growth
• inhibition of angiogenesis
• reduction of DNA synthesis

Acute manifestations of interferon toxicity include influenza-like syndrome, alopecia, injection site reactions, exacerbation of psoriasis and laboratory abnormalities. Chronic manifestations of toxicity include anorexia, weakness and the development of depression.

Since 2011, monoclonal antibodies have been used to treat malignant melanoma. They cause modification of the immune system. They are defined as inhibitors of checkpoints of the body's immune response to melanoma tumour cells.

Monoclonal antibodies include ipilimumab. It can favorably modulate the body's cellular immune response. It doubles the survival time of patients with metastatic melanoma compared to other systemic treatments.

Treatment of metastatic melanoma

The treatment of metastatic melanoma is the responsibility of the surgeon and the oncologist. Unfortunately, it is still relatively unsuccessful. The following are used to treat skin metastases:

• surgical removal
• interleukins
• interferons
• topical cytostatics
• radiotherapy
• photodynamic therapy

Nodal metastases are treated with surgery or radiotherapy. In the case of organ metastases, systemically administered chemotherapy and combined immunochemotherapy are used in addition to surgery.

In some cases, special radiotherapy procedures are used.