The Correct Answer is B: Perform a biopsy with appropriate immunohistochemistry stains
Physical examination revealed a fair-complected man with a 22 × 25 × 7-cm malodorous, fungating growth, with areas of necrosis and hemorrhage. An enlarged left inguinal lymph node was detected. A CT scan disclosed that the tumor extended through the subcutaneous tissue, impinging on the vertebral column.
Chest radiograph showed a few tiny opacities suggestive of metastases. Biopsy of the primary tumor revealed a high-grade, poorly differentiated malignant neoplasm consistent with nodular malignant melanoma; the diagnosis was confirmed by histochemistry results.
The cancer was classified as stage IV. A palliative debulking, designed to ease discomfort and reduce the risk of superinfection, was followed by skin grafting. The patient agreed to a multi-agent chemotherapeutic regimen consisting of paclitaxel(Drug information on paclitaxel), cisplatin(Drug information on cisplatin), and temazolamide (Temodar). Following two rounds of this chemotherapy, the left inguinal lymph node decreased from 15 to 6 cm, indicating clinical response. Enrollment in a clinical trial with an experimental B-raf kinase inhibitor is being pursued.
Despite the many options for the treatment of metastatic melanoma, no consensus has been reached as to the optimal management. Complete response rates to either single- or multi-drug chemotherapeutic regimens have been poor (< 6%), including only modest increases in the median survival.[2-4]
Both palliative or potentially curative surgical intervention can also be considered.[5,6] Palliative surgery can relieve specific symptoms in more than 75% of patients. Potentially curative metastasectomy has been successful with isolated pulmonary, gastrointestinal, subcutaneous, and nodal metastases, with 5-year survival rates in the 20% to 40% range. It remains difficult to explain why some patients with small primary lesions develop early or extensive distant metastasis, while others, even those with a large primary, develop minimal and/or late metastases.
For an in-depth discussion of cutting-edge immunotherapy for metastatic melanoma, see the article by Thumar and Kluger, Ipilimumab: A Promising Immunotherapy for Melanoma