FORT LAUDERDALE, Fla--Once primary melanoma is excised, choosing among adjuvant treatment options is a difficult decision, Daniel G. Coit, MD, of Memorial Sloan-Kettering Cancer Center, said at the National Comprehensive Cancer Network (NCCN) annual meeting. Dr. Coit presented the network's preliminary guidelines for melanoma, along with John A. Thompson, MD, of the University of Washington, Seattle.
Adjuvant treatment and the schedule and intensity of follow-up were the areas that generated the most discussion among the melanoma guidelines panel members, Dr. Coit said.
Dr. Thompson noted that "interferon alfa-2b (Intron A) is the first adjuvant treatment in melanoma that has induced a statistically significant improvement in relapse-free and overall survival."
In considering guidelines for adjuvant treatment, Dr. Thompson said that the NCCN panel focused on "patients who can be rendered surgically free of disease, but who retain a very high risk of relapse in the next five years."
For patients with melanomas less than 4 mm thick, the recommendation is surgery alone. Patients with melanomas greater than 4 mm thick or anyone with positive lymph nodes regardless of thickness should be considered for interferon alfa therapy or a clinical trial, Dr. Thompson said.
For patients who are sentinel node positive, Dr. Thompson said that the preliminary NCCN recommendation is generally to proceed with lymph node dissection. "At that point, if no evidence of residual metastatic disease exists, the clinician may proceed with adjuvant systemic therapy with interferon," he said.
Dr. Coit called detection of recurrence the cornerstone of the follow-up of the cancer patient. He emphasized that the NCCN guidelines for follow-up "are, for the most part, arbitrary, that is, they are points of departure."
Follow-up for Early Melanoma
For early melanoma (stages I and II), the committee adhered to the NCI consensus guideline, Dr. Coit said, which recommends history and physical and skin examination every six months for two years, then annually. Optional follow-up recommendations include chest x-ray, and LDH every 6 to 12 months. He added that, for more advanced disease, "there really are very little data to suggest what we should do."
Patients with thicker melanomas and those with node-positive melanomas recur earlier than those with node-negative or thinner melanomas, he noted. "In node-positive melanomas, about 80% of all recurrences will be seen within the first two years, and by five years, well over 95% of all recurrences will be seen," he said.
Although recurrence is less common in the node-negative and thin melanoma group, the risk of recurrence is spread out over a much longer period of time. "Only about 50% of recurrences are seen by two years, and that curve stretches out to 10 and 20 years," Dr. Coit said.
The NCCN recommends more intensive frequency of follow-up in patients with positive nodes or thick primary melanomas, with yearly follow-up after the fifth year, "looking both at the risk of second primary melanoma, a lifelong event, and the likelihood of a late recurring melanoma," Dr. Coit said.
Optional recommendations for follow-up in these patients are chest x-ray and laboratory studies, including LDH, alkaline-phosphatase, and complete blood cell count, every 6 to 12 months, and abdominal/pelvic/chest CT scan, especially if interferon alfa is being considered, he added.
Dr. Coit emphasized that the NCCN guidelines to date are a "work-in-progress" and will be followed by ongoing review and refinement within the NCCN member institutions.
Dr. Coit cautioned that melanoma is primarily a disease of younger people, and it is crucial that its management in the early phases be determined. "We're in the midst of a melanoma epidemic," he said, "and it's becoming a public health problem, ranking second only to adult leukemia in terms of years of potential life lost."
For patients with in situ melanomas, the NCCN preliminary recommendations for primary treatment include wide excision with a 0.5 cm margin; for those with melanomas less than 1 mm thick, a 1 cm margin; and for those with melanomas measuring between 1 and 4 mm, or greater than 1 mm thick, a wide excision with a 2 cm margin.
In patients who present with stage III melanoma, wide excision of the primary melanoma with a regional lymph node dissection is appropriate, and results in a long-term cure rate of approximately 30% of patients, Dr. Coit said.
For more advanced regional disease, there are many options, he said. Those included in the preliminary NCCN practice guidelines are surgical excision; intradermal injection of nonspecific immunotherapy agents, like BCG (bacillus Calmette-Guérin), DNCB (dinitrochlor-obenzene), or interferon-alfa; hyperther-mic perfusion with melphalan(Drug information on melphalan) (Alkeran); enrollment in a clinical trial; or systemic therapy.
For patients with systemic metastases not amenable to surgical resection, Dr. Coit said, the recommended treatment is systemic chemotherapy with dacarbazine(Drug information on dacarbazine) (DTIC), platinum-based combination therapy, or investigational therapy on a clinical trial.
NCCN Melanoma Guidelines Panel
Alan Houghton, MD
Daniel Coit, MD
William Bloomer, MD
Antonio Buzaid, MD
David Chu, MD
Burton Eisenberg, MD
Joan Guitart, MD
Timothy Johnson, MD
Stanley Miller, MD
Steven Sener, MD
Kenneth Tanabe, MD
John Thompson, MD
Marshall Uriat, MD
Mike Walker, MD