Taking a multidisciplinary approach to in-transit melanoma treatment

Key takeaways:

• The goal for treating in-transit melanoma is local regional control.
• Treatment options include surgery, intralesional therapy, isolated limb infusion or perfusion, systemic therapy and radiation.

CHICAGO — A speaker at the American Society for Dermatologic Surgery Annual Meeting discussed how a multidisciplinary approach may be necessary for the treatment of in-transit melanoma.

“[In-transit melanoma (ITM)] is dermal or subcutaneous deposits of melanoma located between the primary melanoma site and a draining nodal basin,” Luke D. Rothermel, MD, MPH, assistant professor of surgery and section chief of GI and soft tissue malignancies at University Hospitals Cleveland, said during his presentation.

“The goal of treating this local regional disease is local regional control,” Rothermel continued.

For patients with unresectable ITM only, as opposed to those with a concurrent nodal disease or resectable ITM, Rothermel discussed four treatment options.

The first, an oncolytic virotherapy called talimogene laherparepvec (TVEC), is a herpes virus construct that has been genetically modified to hijack tumors’ replication systems while avoiding replication in normal cells. This injectable therapy is FDA-approved for the treatment of patients with advanced melanoma that cannot be completely removed with surgery.

The second treatment option is adding checkpoint inhibition to TVEC, which has been shown to improve patients’ durable response; however, Rothermel states that this option does not improve the progression-free survival or overall survival of patients.

Hyperthermic isolated limb perfusion can be an option for patients with ITM in an extremity, according to Rothermel. Once the limbs vessels are isolated by a tourniquet, high doses of chemotherapy can be directly administered into ipsilateral vessels without risk for toxicity.

On the other hand, physicians may use isolated limb infusion instead, which administers chemotherapy through percutaneous catheters into contralateral groin vessels.

According to Rothermel, limb perfusion and infusion are repeatable procedures with remarkable response rates.

“Surgery, intralesional therapy, isolated limb infusion or perfusion and systemic therapy as well as radiation need to be a part of your multidisciplinary discussion,” Rothermel concluded. “It achieves local regional control, and it is a reasonable combination with systemic therapy to manage disease that is otherwise very dramatic for some of these people.”