Treatment for Metastatic Melanoma

First-Line Treatment Selection

The American Society of Clinical Oncology recommends combination immunotherapy with ipilimumab plus nivolumab as the standard first-line treatment for BRAF wild-type metastatic melanoma, achieving durable responses in 45-50% of patients and a 10-year overall survival rate of 43% 1
For BRAF-mutated metastatic melanoma, the choice between immunotherapy and targeted therapy depends on specific clinical characteristics, such as performance status, disease progression, and LDH levels 1, 3
The European Society for Medical Oncology suggests that BRAF/MEK inhibitor combinations achieve response rates of approximately 70% with rapid onset, but patients with poor prognostic features are likely to progress and require subsequent treatment 1, 2

Surgical resection should be considered for isolated, slowly developing single metastases, including parenchymal organ metastases and central nervous system lesions, with complete (R0) resection as the goal 4, 5, 6, 7

Chemotherapy has a limited role in modern metastatic melanoma treatment and should generally be reserved for patients who have failed immunotherapy and targeted therapy, with dacarbazine being the conventional palliative chemotherapy 4, 5, 6

Systemic immunotherapy or targeted therapy can be effective for brain metastases, and palliative radiotherapy should be considered for symptomatic brain metastases 1, 3, 7
For in-transit metastases, surgical excision is standard treatment when feasible, and isolated limb perfusion with melphalan and tumor necrosis factor can be considered for numerous metastases confined to a limb 4, 5, 6, 7

Delaying immunotherapy in BRAF-mutated patients with favorable prognostic features can result in missed opportunities for long-term durable control, which favors immunotherapy first 1, 2
Using targeted therapy in BRAF wild-type melanoma is not recommended, as these patients should receive immunotherapy 1
Continuing ineffective chemotherapy when modern immunotherapy and targeted therapy options are available can lead to poor outcomes 4
Performing aggressive surgical resection without comprehensive staging can result in unnecessary procedures and poor outcomes 7
Single-agent BRAF inhibition is not recommended, as combination BRAF/MEK inhibition is the standard for targeted therapy 1