Figure 3: Stage IV melanoma immunotherapy treatment algorithm.
All treatment options shown may be appropriate and final selection of therapy should be individualized based on patient eligibility and treatment availability at the physician's discretion. These algorithms represent consensus sequencing suggestions by the panel. (1) All patients should be evaluated for surgical resection before and after immunotherapy treatment. There was level B data for a clinical benefit with surgical resection of completely resectable lesions and first-line surgical resection was a minority opinion (9%) of the consensus panel. (2) The panel recommended a BRAF inhibitor for patients with BRAF-mutated melanoma with poor PS, who have untreated CNS disease and who are not candidates for clinical trials. (3) The panel recommended that immunotherapy be considered in patients with BRAF-mutated melanoma who have been treated with a BRAF inhibitor if their PS improved with treatment and CNS disease is controlled. IL-2 can be considered in those patients who have a good PS and otherwise qualify for IL-2 administration as per local institutional guidelines. (4) The panel recommended that ipilimumab be considered for patients with BRAF-mutated melanoma with an initial poor PS who respond to a BRAF inhibitor and who are not candidates for IL-2 treatment or clinical trials. (5) The panel recommended that chemotherapy be considered in patients who have disease progression on a BRAF inhibitor and immunotherapy or who are not candidates for immunotherapy or clinical trials. (6) The panel was generally enthusiastic about recommending appropriate clinical trials for patients with melanoma. In most cases individual clinical trials should be considered pending patient eligibility and interest. (7) The panel recommended that IL-2 be considered first, provided that patients have a good PS and otherwise meet local institutional guidelines for IL-2 administration. Patients who are not candidates for IL-2 therapy should consider ipilimumab. (8) The panel recommended that patients with BRAF-mutated melanoma and a good PS with no evidence of CNS disease, or with treated CNS disease, consider immunotherapy first and delay a BRAF inhibitor until there is unequivocal evidence of disease progression. Abbreviations: BRAF+, positive for actionable BRAF mutations; BRAF−, negative for actionable BRAF mutations; CNS, central nervous system; IL, interleukin; KIT+, positive for actionable KIT mutations; LDH, lactate dehydrogenase; PS, performance status.
