Systemic chemotherapy for malignant melanoma.

Malignant melanoma is notoriously resistant to chemotherapy. Standard single agents include dacarbazine and the nitrosoureas, but most series treating patients with metastatic melanoma report response rates of about 20%. Occasional patients, however, achieve long term remission, amounting to cure, after such treatment. Adjuvant studies have failed to define any systemic therapy of value after surgery for primary or regional lymph node disease. Combinations of drugs have not been shown to be superior to single agents. Cisplatin and fotemustine are among the newer agents with activity. Isolated limb perfusion with melphalan and systemic therapy with high dose alkylating agents and marrow transplantation suggest that the resistance to conventional concentrations of alkylating agents is not absolute. One strategy to improve the efficacy of alkylating agents may therefore be the modulation of cellular glutathione or glutathione-S-transferase. Biological response modifiers remain of interest, though many of the protocols with the best response rates are impractical for routine use. Many patients with asymptomatic metastatic melanoma should be observed without treatment. Outside clinical trials, it is reasonable to use single agent dacarbazine or lomustine if chemotherapy is required.