Melanoma

Staging

Localized (Stage I-II)

Surgery for stages 0-IIA

Regional (Stage III)

Adjuvant therapy for stages IIB-IIIC

Metastatic (Stage IV)

Systemic therapy for stage IV

Drugs

IFN alpha-2b

approved for stage III high risk

tox
granulocytopenia
increased LFTs
flu symptoms
depression
anorexia
fatigue

Avoid in
autoimmune
chronically immunosuppressed
liver disease
severe neuropsychiatric diseases
life-treat infection

IL-2

approved for metastatic melanoma

administed in ICU

Steroids are CONTRAINDICATED due to risk of infections and GI side effects

tox
capillary leak syndrome
constitutional symptoms
infections
N/V
chills

BRAF/MEK inhibitors

Approved for unresectable or metastatic melanoma w/ BRAF V600 mutations

Dabrafenib + vemurafenib

also approved for adjuvant therapy for pt w/ mutation w/ lymph node involvement following complete resection

trametinib + cobimetinib

tox
skin oddities
pyrexia
diarrhea
eleved CK and LFTs

CTLA4 inhibitors

Ipilmumab

has the highest tox among checkpoint inhibitors

Tox
rash
diarrhea
liver tox
hypophysitis

manage diarrhea and livertox w/ high dose steroids

infliximab second line for diarrhea
mycophendlate second line for liver tox

infliximab contraindicated in liver disease

PD-1 inhibitors

Nivolumab

approved for single agent and in combo w/ ipilmumab for unresectable or metastatic melanoma

approved for adjuvant treatment after complete resection

pembrolizumab

approved as single agent for resectable or metastatic melanoma

Treatment Options

Surgery

Primary treatment

Adjuvant therapy

Non-metastatic
- decrease recurrence time

Nivolumab

Ipilimumab

Dabrafenib/trametinib (BRAF V600)

Topical imiquimod or radiation if exclusion

Metastatic
- extend overall survival

Pembrolizumab

Nivolumab

Nivolumab + Ipilimumab

recommended first line for metastatic melanoma regardless of PDL1 expression

Combo BRAF/MEK inhibitor