The Role of Regional Therapies for in-Transit Melanoma in the Era of Improved Systemic Options

Abstract

The incidence of melanoma has been increasing at a rapid rate, with 4%–11% of all melanoma recurrences presenting as in-transit disease. Treatments for in-transit melanoma of the extremity are varied and include surgical excision, lesional injection, regional techniques and systemic therapies. Excision to clear margins is preferred; however, in cases of widespread disease, this may not be practical. Historically, intralesional therapies were generally not curative and were often used for palliation or as adjuncts to other therapies, but recent advances in oncolytic viruses may change this paradigm. Radiation as a regional therapy can be quite locally toxic and is typically relegated to disease control and symptom relief in patients with limited treatment options. Regional therapies such as isolated limb perfusion and isolated limb infusion are older therapies, but offer the ability to treat bulky disease for curative intent with a high response rate. These techniques have their associated toxicities and can be technically challenging. Historically, systemic therapy with chemotherapies and biochemotherapies were relatively ineffective and highly toxic. With the advent of novel immunotherapeutic and targeted small molecule agents for the treatment of metastatic melanoma, the armamentarium against in-transit disease has expanded. Given the multitude of options, many different combinations and sequences of therapies can be offered to patients with in-transit extremity melanoma in the contemporary era. Reported response and survival rates of the varied treatments may offer valuable information regarding treatment decisions for patients with in-transit melanoma and provide rationale for these decisions.

MRI-Guided Cryoablation of In-Transit Metastases from Cutaneous Melanoma: A Brief Report on a Preliminary Experience

“…The NCCN guidelines provided A. Rauch et al: MRI-Guided Cryoablation of In-Transit Metastases from Cutaneous Melanoma… a wide range of therapeutic options for IT metastases, including surgical resection, intra-lesional and topical treatments, local radiation therapy, regional therapies such as isolated limb infusion (ILI) and isolated limb perfusion (ILP); and systemic agents such as chemotherapies, interferon (IFN) and novel immunologic drugs (anti-CTLA4 and anti-PD-1 antibodies) [2, 6,7]. Our results seem to compare favourably in terms of local tumour control when compared both to local and regional treatments (87.5% of primary local control at 12-months in our series versus up to 89% with local therapies and up to 82% with regional therapies) [2, [6][7][8]. Moreover, CA proved to be well tolerated by all patients who were able to walk 4-6 hours after the procedure; and, all patients were discharged from the hospital as planned on the day following the procedure, without any need of painkillers.…”

A systematic review and meta‐analysis of locoregional treatments for in‐transit melanoma

“…In comparison to primary disease local recurrence, there are significant implications for further treatment and survival . Multiple factors can prohibit surgery, necessitating alternative, locoregionally directed treatments . These include the volume and anatomical distribution of disease, recalcitrant biology, polyrecurrent pattern of progression, required soft‐tissue reconstruction, medical comorbidities, and patient preference.…”

“…Due to the diversity of therapies available and variable clinical responses reported, a comprehensive review is warranted to facilitate selection of the most evidence‐based and efficacious interventions . More recently, with the success of targeted‐ and systemic immunotherapies, the role of these treatments needs to be appraised to define future directions . The aims of this study were to: quantitatively assess the evidence for locoregional treatments available for ITM, to determine the efficacy and relevant morbidity profiles associated with these modalities, and to establish the survival outcomes of patients after locoregional treatment.…”

Do you know your guidelines? Diagnosis and management of cutaneous head and neck melanoma

“…In the setting of a single, in‐transit site, SLNB may be considered . If in‐transit disease is unresectable or if numerous foci exist, other treatment options can be considered to include local radiation and nonsurgical ablation methods . Alternatively, intralesional injections can be used if there is a limited number of in‐transit lesions to targeted.…”