The major modalities of therapy, namely, surgery, radiotherapy, chemotherapy, and immunotherapy, are each of value in selected cases of malignant melanoma. However, because none of these therapies, alone, is capable of curing or controlling some subgroups of melanoma patients, combined modality therapy needs to be used more extensively. Surgery is of particular value in the treatment of primary tumors and in recurrent or regional metastatic disease. Chemotherapy for malignant melanoma has been disappointing. The most active single agent, DTIC, induces only about a 20% response rate, and little or no significant improvement is seen when DTIC is combined with other agents. However, chemotherapeutic agents when utilized by isolation perfusion in the treatment of primary or recurrent melanoma of the extremities, in conjunction with surgical excision of the primary tumor, produce cure rates of approximately 85% in patients with stage I disease and 50% in those with stage II disease. Immunotherapy appears to be of significant value in primary melanoma, and intra-lesional BCG immunotherapy of cutaneous or subcutaneous metastatic lesions has yielded a 50% response rate. Successful combined modality therapy would take into account the natural history and course of the disease. Conventional therapy consists of surgery as primary therapy, followed by chemo- or immunotherapy. Further research is needed to determine if better results can be achieved by altering the sequence of utilization of the various treatment modalities.
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