eMedicine Specialties > Dermatology > Malignant Neoplasms

Malignant Melanoma: Follow-up

Author: Susan M Swetter, MD, Director, Pigmented Lesion and Cutaneous Melanoma Clinic, Professor, Department of Dermatology, Stanford University Medical Center, Veterans Affairs Palo Alto Health Care System
Contributor Information and Disclosures

Updated: Jan 26, 2010

Follow-up

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.69 The risk of new primary melanoma increases in the setting of multiple clinical atypical/dysplastic nevi, family history of melanoma, and atypical mole syndrome or familial atypical mole-melanoma syndrome. 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

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.

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).

  • Cutaneous melanoma (stages I and II)
    • 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
    • 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%).
    • A pooled analysis of high-dose adjuvant IFN-alfa trial results from the United States has shown significantly improved disease-free survival for stage III disease; modest improvement in OS has been observed in 2 prospective randomized studies. Melanoma vaccines/biologic response modifiers show promise in prolonging disease-free survival and OS rates in melanoma patients.
  • Stage IV disease
    • Prognosis for distant metastatic disease is 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 slightly better prognoses than those with other visceral metastases and/or elevated LDH levels. However, survival beyond 1 year occurs in only a minority of stage IV patients.
    • Systemic chemotherapy is the mainstay of treatment, despite 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 is under further investigation. High-dose IL-2 alone, or combined with histamine dihydrochloride, has also shown promise in patients with advanced disease.47
    • As with regional nodal disease, numerous trials are investigating the use of melanoma vaccines (with or without biologic response modifiers) in the treatment of disseminated disease. The hope is that data from the many phase 3 trials in progress worldwide will show improvement in survival for patients with advanced melanoma.

Despite advances in the treatment of metastatic disease, detection and treatment of cutaneous melanoma in its thin, early phase remains the best chance for cure.

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
  • Possible recurrence within the melanoma scar
  • Screening of first-degree relatives, particularly if they have a history of atypical moles

For excellent patient education resources, visit eMedicine's Cancer and Tumors Center and Procedures Center. In addition, see eMedicine's patient education articles Skin Cancer, Skin Biopsy, and Mole Removal.

Miscellaneous

Medicolegal Pitfalls

Clinical or histopathologic misdiagnosis of melanoma or a delay in the clinical diagnosis and skin biopsy may result in thicker tumors with an increased risk of metastasis.

Consensus indicates that skin biopsy results from pigmented lesions suggestive of melanoma should be assessed by a pathologist experienced in the interpretation of melanocytic lesions and a dermatopathologist, whenever possible.

 


More on Malignant Melanoma

Overview: Malignant Melanoma
Differential Diagnoses & Workup: Malignant Melanoma
Treatment & Medication: Malignant Melanoma
Follow-up: Malignant Melanoma
Multimedia: Malignant Melanoma
References
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Further Reading

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Keywords

malignant melanoma, melanoma, skin cancer, cutaneous melanoma, malignancy of pigment-producing cells, malignant melanoma, malignancy of melanocytes, invasive cutaneous melanoma, melanoma in situ, metastatic melanoma, acral melanoma, changing mole, superficial spreading melanoma, nodular melanoma, lentigo maligna melanoma

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Contributor Information and Disclosures

Author

Susan M Swetter, MD, Director, Pigmented Lesion and Cutaneous Melanoma Clinic, Professor, Department of Dermatology, Stanford University Medical Center, Veterans Affairs Palo Alto Health Care System
Susan M Swetter, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, American Society of Clinical Oncology, Eastern Cooperative Oncology Group, Pacific Dermatologic Association, Society for Investigative Dermatology, Society for Melanoma Research, and Women's Dermatologic Society
Disclosure: Nothing to disclose.

Medical Editor

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.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

John G Albertini, MD, Consulting Staff, Dermatologic Surgery, The Skin Surgery Center; Program Director, ACGME accredited Fellowship in Procedural Dermatology
John G Albertini, MD is a member of the following medical societies: American Academy of Dermatology and American College of Mohs Micrographic Surgery and Cutaneous Oncology
Disclosure: Nothing to disclose.

CME Editor

Catherine M Quirk, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania
Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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