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Cutaneous Melanoma Follow-up

  • Author: Susan M Swetter, MD; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Mar 28, 2016
 

Further Outpatient Care

Patients should be monitored regularly after a diagnosis of cutaneous melanoma, particularly in the setting of thicker tumors, because most metastases occur in the first 1-3 years after treatment of the primary tumor. Annual skin examinations are recommended for life because an estimated 4-8% of patients with a history of melanoma develop new primary melanoma, generally within the first 3-5 years following diagnosis.[124] The risk of new primary melanoma increases in the setting of increased nevus count; multiple clinical atypical/dysplastic nevi; family history of melanoma; fair skin/sun sensitivity; prior in situ, nodular, and lentigo maligna melanoma; and male sex.[125] Additionally, individual patient risk factors should be taken into account in the determining the frequency of dermatologic surveillance.

The diagnosis of recurrent/metastatic disease and new primary melanoma depends on a routine evaluation schedule that varies according to the following:

  • Tumor depth
  • The presence of histologic ulceration
  • Mitotic rate in the primary tumor
  • Regional lymph node status
  • Results of the examination of the melanoma scar
  • Results of the examination of regional and distant lymph node basins
  • The presence of hepatosplenomegaly upon abdominal examination
  • Mole pattern and examination findings from the entire cutaneous surface for new primaries
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Complications

Metastasis may occur locally (within or around the primary site), in the regional lymph node basins, or distally in the following sites:

  • Remote skin (away from the melanoma scar)
  • Remote lymph node(s)
  • Viscera
  • Skeletal
  • CNS sites

Disease relapse is seen most commonly in the skin, subcutaneous tissue, and lymph nodes.

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Prognosis

Prognosis is multifactorial and primarily depends on (1) tumor thickness, (2) the presence or absence of histologic ulceration, and (3) lymph node involvement (most important). Despite remarkable advances in the treatment of metastatic disease, detection and treatment of cutaneous melanoma in its thin, early phase remains the best chance for cure.

Cutaneous melanoma (stages I and II) prognosis

Thin primaries (≤1 mm) are associated with a 5-year survival rate of 94-97%, depending on the presence or absence of histologic ulceration and mitotic rate of greater than or equal to 1/mm2 versus less than 1/mm2.

Intermediate-thickness melanoma (1.01-4 mm) is associated with a 5-year survival rate of 68-91%, depending on ulceration and the thickness (1.01-2 mm, 2.01-4 mm) of the primary tumor.

Patients with high-risk tumors (>4 mm) have a 5-year survival rate of 71% without ulceration, compared with 53% with an ulcerated primary.

Ulceration significantly reduces survival at each tumor stage, even when regional lymph nodes are involved.

Stage III disease prognosis

Regional lymph node metastasis is associated with a 5-year survival rate of 38-78%, depending on the number of nodes involved, microscopic or macroscopic (matted nodes/gross extracapsular extension) disease, and ulceration of the primary melanoma. In-transit metastasis/satellite lesions are associated with a 69% 5-year survival rate, with a significantly worse prognosis in the setting of concomitant regional nodal metastasis (40%).

Stage IV disease prognosis

Prior to the advent of checkpoint inhibitors and targeted therapy for melanoma, prognosis for distant metastatic disease was extremely poor, with median survival of only 6-9 months and 5-year survival rates of less than 20%, depending on the site(s) of metastasis. In general, patients with soft tissue, nodal, and isolated lung metastases have had slightly better prognoses than those with other visceral metastases and/or elevated LDH levels. With immune checkpoint blockade or targeted therapy, high overall response rates and disease control has become the norm in patients with unresectable stage III and IV melanoma. Durable complete responses have been observed, particularly with novel immunotherapies.

Systemic chemotherapy is no longer the mainstay of treatment for metastatic melanoma; it is associated with low response rates (< 20%), which also tend to be of short duration.

Biochemotherapy, using standard chemotherapeutic agents with biologic response modifiers such as IL-2, IFN alfa, or granulocyte macrophage colony-stimulating factor, has shown limited success in the management of unresectable stage IV melanoma and no OS benefit or durable responses in patients with metastatic disease.[126] High-dose IL-2 alone, or combined with histamine dihydrochloride, has resulted in durable remission in a very small subset of patients with advanced disease, but is characterized by significant toxicity and need for hospitalization and careful monitoring during drug administration.[63]

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Patient Education

Educate patients with a history of melanoma regarding the following:

  • Sun-protective measures (including sun-protective clothing and sunscreens)
  • Skin self-examinations for new primary melanoma, particularly important in individuals with numerous moles (common or atypical) or a strong family history of melanoma
  • Possible recurrence within the melanoma scar
  • Screening of first-degree relatives, particularly if they have a history of atypical moles
  • Potential referral to a cancer genetics clinic for individuals with 3 or more invasive melanomas (personal or in the same side of the family) or families with 3 or more “cancer events,” including 2 invasive melanomas and 1 pancreatic cancer (or vice versa) for discussion of genetic testing for the CDKN2A ( P16) mutation. [127] (However, a negative result would not affect the need for ongoing dermatologic surveillance in patients at increased risk or history of multiple primary melanomas.)

For patient education resources, visit the Cancer and Tumors Center and Procedures Center, as well as Skin Cancer, Skin Biopsy, and Mole Removal.

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Contributor Information and Disclosures
Author

Susan M Swetter, MD Director, Pigmented Lesion and Melanoma Program, Professor, Department of Dermatology, Stanford University Medical Center and Cancer Institute, Veterans Affairs Palo Alto Health Care System

Susan M Swetter, MD is a member of the following medical societies: American Academy of Dermatology, Women's Dermatologic Society, American Society of Clinical Oncology, Society for Melanoma Research, Eastern Cooperative Oncology Group, American Medical Association, Pacific Dermatologic Association, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

John G Albertini, MD Private Practice, The Skin Surgery Center; Clinical Associate Professor (Volunteer), Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine; President-Elect, American College of Mohs Surgery

John G Albertini, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery

Disclosure: Received grant/research funds from Genentech for investigator.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Acknowledgements

Günter Burg, MD Professor and Chairman Emeritus, Department of Dermatology, University of Zürich School of Medicine; Delegate of The Foundation for Modern Teaching and Learning in Medicine Faculty of Medicine, University of Zürich, Switzerland

Günter Burg, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, International Society for Dermatologic Surgery, North American Clinical Dermatologic Society, and Pacific Dermatologic Association

Disclosure: Nothing to disclose.

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Superficial spreading melanoma, left breast, 1.3-mm Breslow depth.
Lentigo maligna melanoma, right lower cheek. Centrally located erythematous papule represents invasive melanoma with surrounding macular lentigo maligna (melanoma in situ).
Acral lentiginous melanoma (1-mm Breslow depth), left sole. Diagnostic punch biopsy site is located superiorly.
Malignant melanoma. Courtesy of Hon Pak, MD.
Cutaneous melanoma with characteristic asymmetry, irregular borders, and color variation. Courtesy of Wendy Brick, MD.
Table. AJCC 2002 Revised Melanoma Staging
Stage TNM Classification Histologic/Clinical Features 5-Year Survival Rate, %
0 Tis N0 M0 Intraepithelial/in situ melanoma 100
IA T1a N0 M0 ≤1 mm without ulceration and mitotic rate < 1/mm2 97
IB T1b N0 M0



T2a N0 M0



≤1 mm with ulceration or mitotic rate ≥1/mm2



1.01-2 mm without ulceration



91-94
IIA T2b N0 M0



T3a N0 M0



1.01-2 mm with ulceration



2.01-4 mm without ulceration



79-82
IIB T3b N0 M0



T4a N0 M0



2.01-4 mm with ulceration



4 mm without ulceration



68-71
IIC T4b N0 M0 >4 mm with ulceration 53
IIIA T1-4a N1a M0



T1-4a N2a M0



Single regional nodal micrometastasis, nonulcerated primary



2-3 microscopic positive regional nodes, nonulcerated primary



78
IIIB T1-4b N1a M0



T1-4b N2a M0



T1-4a N1b M0



T1-4a N2b M0



T1-4a/b N2c M0



Single regional nodal micrometastasis, ulcerated primary



2-3 microscopic regional nodes, nonulcerated primary



Single regional nodal macrometastasis, nonulcerated primary



2-3 macroscopic regional nodes, no ulceration of primary



In-transit met(s)* and/or satellite lesion(s) without metastatic lymph nodes



54-59
IIIC T1-4b N2a M0



T1-4b N2b M0



Any T N3 M0



Single macroscopic regional node, ulcerated primary



2-3 macroscopic metastatic regional nodes, ulcerated primary



4 or more metastatic nodes, matted nodes/gross extracapsular extension, or in-transit met(s)/satellite lesion(s) and metastatic nodes



40
IV Any T any N M1a



Any T any N M1b



Any T any N M1c



Distant skin, subcutaneous, or nodal mets with normal LDH levels



Lung mets with normal LDH



All other visceral mets with normal LDH or any distant mets with elevated LDH



< 20
*Met is metastasis.
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