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Treatment of Disseminated Melanoma

Key Points Surgical resection should be considered for all patients with limited numbers of metastatic sites. Standard cytotoxic chemotherapy has limited efficacy in metastatic melanoma, with response rates in the 10–20% range and short-lived response durations. High-dose IL-2 is associated with a small percentage of complete and durable responses, but is limited to a subgroup of patients with good performance status owing to its toxicity. CNS…

Imaging Work-up of the Patient with Melanoma

Key Points Imaging is heavily utilized in the diagnosis and management of melanoma patients but the utility of imaging depends upon the goal in the context of the clinical disease setting. For staging purposes, little evidence supports comprehensive body imaging assessment in asymptomatic early-stage melanoma patients. High-frequency ultrasound can augment the sensitivity of sentinel lymph node biopsy assessment of regional nodal disease. Routine follow-up of melanoma…

Targeted Therapy for Melanoma

Key Points A number of targets in melanoma cells and the melanoma tumor microenvironment exist. Early targeted clinical studies against the oncogenic form of B-Raf (V600E) using PLX-4032 have shown promising results. Rational drug combinations will prevent inevitable drug resistance using single-agent therapies. Introduction Conventional systemic chemotherapies and immunotherapies have not translated into clinically significant benefit for the treatment of melanoma and other skin cancers over…

Vaccine Therapy for Melanoma

Key Points Vaccine therapy is promising but still an investigational treatment for melanoma. Vaccines can be derived from peptides, allogeneic tumor cell lines, or autologous tumor cells and have demonstrable activity in preclinical studies and phase I/II clinical trials. Most phase III vaccine trials have failed to show benefit; however, more appropriate patient selection may improve outcomes. Future strategies involving the combination of vaccine therapy with…

Adjuvant Therapy for Cutaneous Melanoma

Key Points Chemotherapy regimens, non-specific immunostimulants and vaccines alone have failed to show any survival benefit in the adjuvant setting. High-dose interferon-α2b is the only approved drug shown to improve relapse-free and overall survival in large multi-institutional randomized controlled trials in melanoma patients with high risk for relapse. High-dose interferon-α2b has significant side effects and financial cost, necessitating the identification of subgroups of patients who would…

Radiation Therapy in the Treatment of Skin Cancers

Key Points Radiation therapy is curative for >90% of primarily treated basal and squamous cell carcinomas of the skin; the cosmetic appearance years later is a function of the manner in which the treatment course is fractionated. Malignant melanomas are the least sensitive type of skin tumor; however, 25% of metastatic malignant melanomas completely regress following radiation therapy. Elective irradiation of high-risk tumor beds substantially improves…

Reconstructive Surgery for Skin Cancer

Key Points Strategies employed in skin cancer reconstruction balance the requirements of the resulting wound defect – location, dimension, functional properties and aesthetics – to achieve the goal of a well-healed durable reconstruction with minimal donor morbidity. Options for reconstruction of skin cancer defects range from primary closure, to skin grafts, local flaps, regional flaps and microvascular free flaps, depending on the complexity of the defect…

Regional Lymph Node Surgery in Melanoma Patients

Key Points The goal of regional lymph node surgery is to remove tumor that has spread to the nodes and thereby improve patient outcomes. Lymphatic mapping and sentinel lymph node biopsy has become the standard of care for the nodal staging of patients with intermediate and high risk stage I and II primary melanoma. The American Joint Committee on Cancer (AJCC) Melanoma Staging Committee states that…

Surgical Excision of Melanoma

Key Points Surgical excision is the cornerstone for the initial management of primary melanoma. The major focus of surgical excision for melanoma is to remove the primary tumor and any local disease. The initial treatment for melanoma should include excision with 5 mm margins (for in-situ lesions), 1 cm margins (for tumors 0.01–1.00 mm of invasion), 1–2 cm margins (for tumors 1.01–2.00 mm of invasion), 2…

Treatment of Disseminated Non-Melanoma Skin Cancers

Key Points Basal cell carcinomas only rarely disseminate widely. Squamous cell carcinoma of the skin has a variable risk of distant metastasis up to 16%. Platinum-based combination therapy is used to treat both metastatic basal and squamous cell carcinoma; data from randomized trials are lacking. Merkel cell carcinoma is an aggressive malignancy of the skin which frequently metastasizes. It is treated in a similar manner to…

Mohs Surgery

Key Points Mohs micrographic surgery (MMS) involves the extirpation of tumor and correct processing of tissue with frozen section histology to ensure that 100% of the margin is examined and has the advantage of sparing normal tissue. MMS has the highest cure rate for both primary and recurrent basal and squamous cell carcinomas. MMS is a useful technique for the management of some melanomas and less…

Surgical Excision for Non-Melanoma Skin Cancer

Key Points Non-melanoma skin cancer (NMSC) is the most common type of cancer and has multiple management options. Surgical excision remains an efficient, effective, and safe method for the treatment of these tumors, particularly with thorough perioperative planning. Excision has advantages over destructive treatment modalities because it allows for histologic evaluation of margins and tumor characteristics that may influence further management. Various patient and tumor qualities…

Photodynamic Therapy in Skin Cancer

Key Points Photodynamic therapy (PDT) is a selective non-invasive therapy for non-hyperkeratotic actinic keratoses, in-situ squamous cell carcinoma, and superficial and thin nodular basal cell carcinomas. PDT offers particular advantages for large and multiple lesions and those in sites where standard therapies have limitations. Field therapy with PDT has potential as a preventive therapy for non-melanoma skin cancer. Superiority of cosmetic outcome following PDT is often…

Immune Response Modulators in the Treatment of Skin Cancer

Key Points Interferons (IFNs) have antiproliferative, antiangiogenic and immunomodulatory properties that can be used to treat skin cancer, including malignant melanoma, Kaposi sarcoma (KS), basal cell carcinoma (BCC) and cutaneous T-cell lymphoma (CTCL). An immune response modifier stimulates both innate and acquired immune responses, including induction of IFNs, interleukin (IL)-12, and tumor necrosis factor-α (TNF-α). A topical immune response modifier (imiquimod) is now being used for…

Topical Treatment of Skin Cancer

Key Points DNA analogs are effective in treating actinic keratoses. Immune response modifiers are effective in treating actinic keratoses, squamous cell carcinoma and basal cell carcinoma through immunomodulation. Inhibition of cyclo-oxygenase enzymes is effective in ablating actinic keratoses. Other compounds are being evaluated for their therapeutic effects as topical chemotherapeutic agents against skin cancer. Topical chemotherapy combined with physical modalities may be the most effective approach…

Cryosurgery

Key Points Comparable cure rates to other procedures. Cryogen: liquid nitrogen. Fast freeze, slow thaw. Excellent cosmetic results. Combination treatments provide enhanced results. Introduction Once a premalignant or malignant skin lesion is diagnosed, the physician decides among the multiple surgical and non-surgical treatment options having comparable cure rates for the appropriate course of action for the patient's needs. Cryosurgery stands among the ablative methods that have…

Curettage and Electrodesiccation

Key Points Curettage and electrodesiccation (CE) is an expedient method of treating many non-melanoma skin cancers (NMSC). Cure rates and cosmetic outcome for CE of NMSC are site- and lesion-dependent. The most important aspect of CE is choosing the correct lesion to treat. Careful incorporation of proper lesion selection and good technique make CE a valuable therapeutic technique in the treatment of uncomplicated NMSC. Introduction Curettage…

Biopsy Techniques

Key Points Proper biopsy is critical in the diagnosis and management of skin cancers. Melanocytic lesions should be removed with an excisional biopsy where possible in order to obtain the most accurate diagnosis and prognostic factors although there is no evidence that an incisional biopsy adversely affects prognosis. Non-melanocytic lesions can be removed with a shave biopsy or other incisional techniques. Introduction The biopsy is a…

Clinical Genomics for Melanoma Detection

Key Points Recent findings provide proof-of-principle that adhesive tape stripping of pigmented lesions suspicious for melanoma, coupled with epidermal genetic information retrieval (EGIR) and gene expression profiling, can be used to discern melanoma from nevi and solar lentigines. Genes differentially expressed between melanoma and nevi, as identified through these EGIR-harvested specimens, are biologically relevant to disease biology. Class prediction modeling of these EGIR-based genomic data produced…

Confocal Microscopy in Skin Cancer

Key Points Reflectance confocal microscopy (RCM) enables imaging of skin lesions at cellular-level resolution either at the bedside ( in vivo ) or in freshly excised tissue ( ex vivo ). Like dermoscopy, in-vivo RCM acquires images in the horizontal plane ( en face ), allowing RCM investigation of tissue pathology underlying dermoscopic structures of interest. RCM is a promising technique for the non-invasive diagnosis of…