Cutaneous Melanoma Guidelines

Updated: Apr 29, 2019
  • Author: Susan M Swetter, MD; Chief Editor: Dirk M Elston, MD  more...
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Guidelines

Clinical Practice Guidelines

American Academy of Dermatology clinical practice guidelines

Guidelines have been released by the American Academy of Dermatology on the evaluation and management of primary cutaneous melanoma. [134]

Evidence strongly indicates that Breslow thickness, ulceration, and dermal mitotic rate are important predictors of patient outcome in primary cutaneous melanoma.

The recommended first-line treatment for any-thickness primary cutaneous melanoma, as well as for melanoma in situ, is surgical excision with histologically negative margins; tumor thickness should dictate the margins.

Surgical margins for invasive cutaneous melanoma, as measured clinically around the primary tumor, should be a minimum of 1 cm and a maximum of 2 cm, although narrower margins can be used to accommodate function and/or anatomic location. It is recommended that the excision be as deep as, but not inclusive of, the fascia.

It is not recommended that asymptomatic patients with newly diagnosed stage 0-II primary cutaneous melanoma undergo baseline radiologic imaging and laboratory studies.

For cutaneous melanoma at baseline, radiologic imaging and laboratory studies should be conducted only to assess the specific signs or symptoms of synchronous metastasis (regional nodal or distant).

At baseline or when physical examination of lymph nodes is equivocal and requires surveillance, the use of lymph node ultrasonography is encouraged. Surveillance with such imaging is also encouraged in the following patients:

  • Those who meet criteria for sentinel lymph node biopsy (SLNB) but do not undergo the procedure
  • Patients in whom SLNB is not possible or is technically unsuccessful (eg, because lymphoscintigraphic dye migration has failed and a draining sentinel lymph node cannot be identified)
  • Those in whom, despite a positive SLNB, complete lymph node dissection is not performed

Regular clinical follow-up represents the most important strategy for detecting cutaneous melanoma recurrence. The need for further radiologic or laboratory studies to detect local, regional, or distant metastatic disease should be determined via history (review of systems) and physical examination findings.

Patients should be taught self-examination of the skin and lymph nodes in order to detect recurrent disease or new primary cutaneous melanoma.

For the first 3 months of BRAF inhibitor monotherapy, patients with numerous squamoproliferative neoplasms should undergo dermatologic evaluation every 2-4 weeks, although less skin toxicity is associated with the standard treatment, combination BRAF/MEK inhibition.

Patients being treated with immune checkpoint inhibitors should undergo dermatologic evaluation within the first month of therapy, with such assessment being continued as needed to manage dermatologic adverse effects.

National Comprehensive Cancer Network clinical practice guidelines

Guidelines on systemic therapy for metastatic or unresectable cutaneous melanoma and recommendations for adjuvant systemic therapies were released in April 2019 by the National Comprehensive Cancer Network. [135]

Systemic therapy for metastatic or unresectable disease

Recommended first-line therapy (metastatic or unresectable disease):

  • Anti–programmed cell death protein 1 (PD1) monotherapy: Pembrolizumab, nivolumab

  • Combination targeted therapy for BRAF V600–activating mutation (preferred if clinically necessary for early response): Dabrafenib/trametinib, vemurafenib/cobimetinib, encorafenib/binimetinib

  • Useful in certain circumstances: Nivolumab/ipilimumab

Recommended second-line or subsequent therapy (disease progression or maximum clinical benefit from BRAF-targeted therapy):

  • Preferred regimens: Anti-PD1 monotherapy (pembrolizumab, nivolumab); nivolumab/ipilimumab; combination targeted therapy for BRAF V600–activating mutation (dabrafenib/trametinib, vemurafenib/cobimetinib, encorafenib/binimetinib)

  • Other regimens: Ipilimumab; high-dose interleukin 2 (IL-2)

  • Useful in certain circumstances: Ipilimumab/intralesional talimogene laherparepvec (T-VEC); cytotoxic agents; imatinib for tumors with activating mutations of KIT; larotrectinib for NTRK gene fusion–positive tumors

Recommended adjuvant systemic therapies

For stage III (sentinel lymph node positive) disease:

  • Primary treatment: Wide local excision of primary lesion and sentinel lymph node biopsy, followed by complete lymph node dissection or nodal ultrasound surveillance

  • Recommended options: Observation, nivolumab, pembrolizumab, combination dabrafenib/trametinib

For stage III (clinically positive nodes [no in-transit or satellite metastases]) disease:

  • Primary treatment: Wide local excision of primary lesion and complete lymph node dissection

  • Recommended options: Observation, nivolumab, pembrolizumab, combination dabrafenib/trametinib

For stage III (clinical or microscopic satellite/in-transit) disease:

  • Primary treatment: Complete surgical excision to clear margins

  • Recommended options: Observation, nivolumab, pembrolizumab, combination dabrafenib/trametinib

For stage IV resectable disease:

  • Primary treatment: Complete resection

  • Recommended options: Observation, high-dose ipilimumab (recommended only if patient has prior exposure to anti-PD1 therapy), nivolumab, pembrolizumab

For local satellite/in-transit disease recurrence:

  • Primary treatment: Complete surgical excision to clear margins

  • Recommended options: Observation, nivolumab, pembrolizumab, combination dabrafenib/trametinib

For nodal recurrence:

  • Primary treatment: Excise nodal metastasis and complete lymph node dissection (if incomplete or no prior complete lymph node dissection)

  • Recommended options: Observation, high-dose ipilimumab (recommended only if patient has prior exposure to anti-PD1 therapy), nivolumab, pembrolizumab, combination dabrafenib/trametinib