MEDLINE and IOWA database search from January 1990 to December 1998.
DATA EXTRACTION: Clinical trials and review articles were selected and classified to answer questions considered of clinical relevance.
RESULTS: Patients with stage I, II, and III
melanoma should undergo excision after biopsy. In patients with stage IV
melanoma, surgical excision of metastatic
melanoma is not considered curative but can provide palliation and improve quality of life. Therapeutic
lymph node dissection should be performed in patients with
melanoma in stages III and IV once pathologic confirmation is obtained. Patients at high risk for recurrence or
metastasis may also be considered for elective node dissection. Adjuvant
therapy after surgery excision is not a standard of care in patients with stage I and IIa
melanoma. In patients with stage IIb and III
melanoma, the best results have been obtained with high doses of
interferon alfa-2b, although toxicity is of concern. Isolated limb perfusion with
melphalan adjuvant to surgery has demonstrated clinically significant benefit in patients with locally recurrent
melanoma and in-transit
metastases. Studies comparing efficacy and quality of life with this technique or with high doses of
interferon alfa-2b are needed. The technique cannot be recommended for high-risk primary
melanoma of an extremity with no clinical evidence of metastatic disease.
CONCLUSIONS: To date,
dacarbazine still appears to be the treatment of first choice in metastatic
melanoma, outside of a clinical trial. The combination of
chemotherapy with
interferon alfa-2b or
interferon alfa-2a enhances toxicity without a significant survival advantage.
Aldesleukin may be an alternative in selected patients when other treatments have failed, but the higher toxicity and cost must be considered.