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Stage IV Melanoma

Short summary

26-year-old patient was diagnosed with stage 4 melanoma with massive metastatic spreading around the lymph node, and underwent surgical treatment: radical lymphoadenectomy of the right armpit, splenectomy, and resection of two subcutaneous lesions. Chemotherapy is also planned.

Patient's questions
1) What therapy would you suggest?

2) Prognosis?

3) Centers of excellence in Italy and/or Europe?

4) Experimental therapy ?
Medical Background

 26 years oldFamily history positive for diabetes and vascular disease. No history of cancer nor of melanoma in the family. White skin with clear phototype , rutilo (red hair, lentigo). Height 177 cm; weight 62 kg. , myopia (11 diopters). Silent medical history.

September 2004: removal of a small nevus on the right arm that she had constantly stroked. The pathology report reads: combined nevus (junctional Spitz) major axis of 0.7 cm with disease-free margins. Upon review on 02/2009 Dr reports: Melanoma with superficial diffusion, moderately pigmented, no ulceration, with epithelioid cells, level III , 0,92 mm thick, TIL present, mitosis 1-6 per mm², associated with combined melanic nevus, margins and apexes are disease free.
In December 2008, self-discovery of a lymph node at the right armpit, LDH 297 (v.n. 190-450) resected.
01/2009 : 7x4x3 cm with irregular surface. Massive metastatic melanoma spreading around the lymph node and with large necrotic areas. TIL absent. Furthermore, resection of skin nevus on the left knee: combined warty nevus with disease-free margins. CT scan of 01/2009 and of CT/PET of 01/2009 both revealed spleen involvement of 2.5cm, two subcutaneous lesions of 2cm, one on the left shoulder blade at the level of the infraspinatus muscle on the posterior axillary line, the other on the right shoulder blade at 4cm from the spine .This last one was PET negative.
On 022009 the patient underwent surgical treatment performed by Dr of Milan Cancer Institute (Istituto Nazionale dei Tumori di Milano) attempting to eradicate the disease: radical lymphoadenectomy of the right armpit, splenectomy, resection of both subcutaneous lesions. The pathology report was transmitted only orally so far: evidence of disease in all the areas investigated. Post-op complications included constipation and abdominal pain.
On 02/2009 CT of the abdomen was performed which proved negative for surgical complications or other lesions.
On 02/2009 evidence of a new subcutaneous node of 1.8 x 0.7 cm on the right arm in the anterocubital region. Restaging is scheduled in March; chemotherapy planned for 03/2009 with CVD regimen (Cisplatin 30 mg/mq gg 1-3, Vindesin 2,5 mg/mq g 1, Decarbazina 250 mg/mq gg 1-3) q 21 with re-evaluation after 4 cycles.


Medical opinion
This patient has stage  4 melanoma. She has distant mets and the approach should be:
systemic therapy. Without therapy her  median survival is   8-12 months. -
The relevant therapy options include:
-       chemotherapy as a single agent  or combination -chemotherapy. This has a response rate of around 10-30% but the response is not durable and lasts only few months.

-       immunotherapy-Vaccines-response rate of only 1-3%

-       immunotherapy-Anti-CTLA-4- still experimental-response rate of  15%. There are major side effects observed in 20-30-% . Some of the clinical responses may be durable.

-       IL-2-high dose or in combination with chemotherapy -this is the standard of care in USA. In the case of soft tissue mets [like the patient] the response can reach 30-40% with some of the pts achieving a durable complete response[CR] and even cure.

-       TIL PROTOCOL-still experimental but preliminary results are encouraging with more  than  50% response. This protocol can be given in the NCI[USA] or at ELLA  INSTITUTE. This is probably the best option.