Melanoma Treatment: Stage III

Stage III Melanoma

Stage III melanoma is when there is a spread into the nearby skin, or more commonly, the lymph nodes or glands. Initially, a biopsy is performed and the pathology will show the Breslow Level or depth of the melanoma; and then if it measures from .76-1.00, a Sentinel Node Biopsy will be recommended. See more on Pathology and Sentinel Node Biopsy under the tab Melanoma Info.

The difficulty lies in figuring out if the melanoma cells are still active in the body perhaps traveling to create a tumor in other organs or tissue. Ideally, you want something like a pre-emergent weed killer, which is called adjuvant therapy that eliminates these cells before they can colonize into a tumor.  Alpha interferon was previously approved by the FDA for stage III, but less likely to be prescribed currently. Scientifically based evidence shows no overall survival advantage to this therapy and the toxicity can make it intolerable.

The new immunotherapies have taken the place of interferon for adjuvant therapy.  Yervoy was approved for stage III initially, in 2015, but now as of 2017, doctors are moving towards the PD1 drugs for adjuvant therapy in stage III.  Opdivo has been approved by the FDA and soon Keytruda will gain similar approval.  Some oncologists feel that these drugs should be prescribed judiciously, that is, only in high risk situations.  All have side effects that you may want to avoid until the need arises.

Other changes are occurring in stage III. Complete Node Dissection was recently found to not extend overall survival, especially if the detection of micro-mets are found in the nodes.  The quality of life issues and likelihood that the melanoma has spread beyond the nodes indicates this may be an outdated procedure.

In addition, there are two adjuvant therapies for melanoma that are designed to treat in-transit lesions that have spread to the surface below the skin. These are called intralesional therapies, and the idea behind them is to inject an agent that destroys the melanoma lesion and also create a bystander effect to other melanoma cells. The two currently tested therapies are called T-vec and Pv-10. Combining these agents with the immunotherapies looks even more promising.

Patients now have an adjuvant therapy choice for the first time in 20 years!  The Braf/Mek drugs for those who are BRAF positive may also enter the picture of available drugs.

Source: Melanoma: Not Just Skin Cancer, by Catherine M. Poole; Contributing editors: Keith Flaherty, MD, DuPont Guerry, MD and Jedd Wolchok, MD, 2015.

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UPDATED: September 1, 2018