Malignant Melanoma Guidelines

Updated: Feb 17, 2019
  • Author: Winston W Tan, MD, FACP; Chief Editor: Dirk M Elston, MD  more...
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Guidelines

Guidelines Summary

Guidelines contributors:  Wesley Wu, MD,  Resident Physician, Department of Dermatology, Baylor College of Medicine; Mohsin R Mir, MD, Director, High Risk Skin Cancer Clinic, Assistant Professor, Mohs Surgery, Laser and Cosmetic Surgery, Department of Dermatology, Baylor College of Medicine

Screening

In 2016, the U.S. Preventive Services Task Force (USPSTF) concluded there is not enough evidence to recommend for or against routine screening (total body examination by a primary care physician or patient self-examination) for early detection of skin cancers in the adult general population. [85]  

The USPSTF did note the following clinical considerations:

  • Skin cancer of any type occurs more commonly in men than in women and among persons with a fair complexion, persons who use indoor tanning beds, and persons with a history of sunburns or previous skin cancer. 
  • Specific risk factors for melanoma include having an atypical mole, multiple (ie, ≥100) moles, and having a family history of melanoma.
  • The risk of melanoma increases with age; the median age at diagnosis is 63 years, and the median age at death is 69 years.
  • Clinical visual skin examination should assess skin lesions for asymmetry, border irregularity, color variability, diameter greater than 6 mm or evolution over time (ABCDE criteria)
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Clinical Presentation and Workup

Guidelines from the American Academy of Dermatology (AAD), established in 2011 and updated in 2019, are as follows [86, 87] :

  • Skin biopsy remains the first step to establish a definitive diagnosis of cutaneous melanoma.

  • Preferred biopsy technique is a narrow excisional/complete biopsy with 1- to 3-mm margins that encompass the entire breadth of lesion and is of sufficient depth to prevent transection at the base. Diagnostic excisional biopsy can be accomplished by (1) elliptical (fusiform) excision, (2) punch excision around the clinical lesion, or (3) deep shave/saucerization to a depth below the anticipated plane of the lesion, usually extending to the deep reticular dermis.

  • Partial/incomplete sampling (incisional biopsy) is acceptable for lesions whose large size or location in a challenging anatomic site (eg, facial, acral) precludes excisional biopsy, and for lesions with low clinical suspicion or uncertainty of diagnosis. Such biopsies should include the most clinically and/or dermoscopically atypical portion(s) of the lesion

  • Narrow-margin excisional biopsy may be performed if an initial partial biopsy is inadequate for diagnosis or microstaging, but it should not generally be performed if the initial specimen meets the criteria for consideration of sentinel lymph node biopsy.

  • Dermoscopy can improve diagnostic accuracy in lesions of clinical concern; it may help direct optimal and adequate tissue sampling of very large lesions or those in cosmetically or functionally sensitive areas.

  • Prebiopsy photographs are an important aid to clinical/pathologic correlation and help to prevent wrong-site surgery if further treatment is required. Photographs may be taken by the patient and/or health care provider and should include a regional photograph that encompasses anatomic landmarks.

  • Findings from history and physical examination should direct need for further studies to detect local, regional, and distant metastasis

  • Ancillary diagnostic molecular techniques (eg, comparative genomic hybridization; fluorescence in situ hybridization, gene expression profiling [GEP]) may be used for equivocal melanocytic neoplasms, but routine molecular testing, including GEP, for prognostication is discouraged until better use criteria are defined. Testing of the primary cutaneous melanoma for oncogenic mutations (eg, BRAF, NRAS) is not recommended in the absence of metastatic disease.

The 2015 guidelines from the European Society of Medical Oncology (ESMO) require diagnosis based on a full-thickness excisional biopsy with a minimal side margin that has been processed by an experienced pathology institute. Histology reports should include the following [88] :

  • Information on the type of melanoma
  • Actinic damage
  • Maximum vertical thickness in millimetres
  • Information on mitotic rate in case of pT1
  • Presence of ulceration
  • Presence and extent of regression
  • Clearance of the surgical margins

Physical examination with special attention to other suspicious pigmented lesions, tumour satellites, in-transit metastases, regional LN and distant metastases is requried. Imaging is not needed for low-risk melanomas but is required in higher tumor stages for accurate staging. [88]

The National Comprehensive Cancer Network (NCCN) supports the concept that most melanoma recurrences are diagnosed clinically. Current NCCN guidelines state that no further workup (ie, baseline laboratory tests and imaging studies) is required in stage 0 (melanoma in situ) and for asymptomatic patients with stage IA, IB, or IIA melanoma. (Physician Quality Reporting System [PQRS] measure #224 concerns overutilization of imaging studies in melanoma.)

Current NCCN guidelines do not recommend surveillance (follow-up) laboratory or imaging studies for asymptomatic patients with stage IA, IB, and IIA melanoma (ie, tumors ≤4 mm depth). Imaging studies (chest radiograph, CT and/or PET-CT) should be obtained as clinically indicated for confirmation of suspected metastasis or to delineate the extent of disease. [21]

The NCCN advises that imaging studies may be considered to screen for recurrent/metastatic disease in patients with stage IIB-IV disease, although this recommendation remains controversial. Routine laboratory or radiologic imaging in asymptomatic melanoma patients of any stage is not recommended after 5 years of follow-up. [21]

While abnormal laboratory test results are rarely the sole indicator of metastatic disease, serum lactate dehydrogenase (LDH) levels are incorporated into the American Joint Committee on Cancer (AJCC)  melanoma staging guidelines for the classification of stage IV (distant) disease. Elevated LDH levels are associated with worse survival in this subgroup. [25]

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Surgical Management

American Academy of Dermatology (AAD) recommendations for surgical management of primary cutaneous melanoma are as follows [87] :

  • Surgical excision with histologically negative margins is the recommended and first-line treatment for primary cutaneous melanoma of any thickness, as well as for melanoma in situ.
  • Surgical margins should be based on tumor thickness. 
  • Depth of excision is recommended to (but not including) the fascia.
  • Sentinel lymph node biopsy, when indicated, should be performed before wide excision of the primary tumor, and in the same operative setting, whenever possible.
  • Mohs micrographic surgery or staged excision with paraffin-embedded permanent sections may be utilized for melanoma in situ, lentigo maligna type, on the face, ears, or scalp for tissue-sparing excision and exhaustive histologic assessment of peripheral margins.
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Sentinel Lymph Node Dissection

The melanoma guidelines from the National Comprehensive Cancer Network (NCCN) do not recommend sentinel lymph node biopsy for patients with in situ melanoma (stage 0). [21]

Evidence supporting routine sentinel lymph node biopsy for patients with thin melanomas (T1; Breslow thickness < 1 mm) is lacking and recommendations remain controversial. The NCCN does not recommend sentinel lymph node biopsy for patients with lesions 0.75 mm or thinner. [2] ESMO recommends sentinel lymph node biopsy with lesions >1 mm and/or ulceration for precise staging. In addition, sentinel lymph node biopsy should be discussed with patients with a T1b tumor greater than 0.75 mm. [88]

The American Academy of Dermatology (AAD) recommends consideration of sentinel lymph node biopsy in patients with lesions, including those less than 0.76 mm, with any of the following high-risk features [86, 87] :

  • Ulceration
  • Mitosis
  • Angiolymphatic invasion
  • Positive deep margin
  • Young patient age

However, data suggest that the presence of a single mitotic figure may not correlate well with sentinel node status in thin lesions. [89]  In addition, the presence of regression in thin lesions is associated with a lower risk of nodal metastasis. [90]

The 2018 update of joint guidelines from the American Society of Clinical Oncology (ASCO) and Society of Surgical Oncology (SSO) includes the following recommendations [27] :

  • Routine sentinel lymph node biopsy is not recommended for patients with thin melanomas that are T1a (non-ulcerated lesions < 0.8 mm in Breslow thickness).
  • Sentinel lymph node biopsy may be considered for thin melanomas that are T1b (0.8 to 1.0 mm Breslow thickness or < 0.8 mm Breslow thickness with ulceration) after a thorough discussion with the patient of the potential benefits and risk of harms associated with the procedure.
  • Sentinel lymph node biopsy is recommended for patients with intermediate-thickness melanomas (T2 or T3; Breslow thickness of >1.0 to 4.0 mm).
  • Sentinel lymph node biopsy may be recommended for patients with thick melanomas (T4; > 4.0 mm in Breslow thickness), after a discussion of the potential benefits and risks of harm.

In the case of a positive sentinel lymph node biopsy, completion lymph node dissection (CLND) or careful observation are options for patients with low-risk micrometastatic disease, with due consideration of clinicopathologic factors. For higher-risk patients, careful observation may be considered only after a thorough discussion with patients about the potential risks and benefits of foregoing CLND. [27]

 

 

 

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Mohs Surgery

The NCCN cites a study of Mohs micrographic surgery (MMS) that employed MMS enhanced by immunohistochemical staining as the primary treatment modality for melanoma in situ, which resulted in 99% removal of melanoma in situ when a total surgical margin of 9 mm was used, versus an 86% rate of removal with 6-mm margins. The stain comprised antibodies to a melanoma antigen recognized by T cells (MART-1). [21, 91]

The appropriate-use criteria for MMS from the AAD, American College of Mohs Surgery (ACMS), American Society for Dermatologic Surgery Association (ASDSA), and the American Society for Mohs Surgery (ASMS) further state that MMS is appropriate for all recurrent melanoma in situ and lentigo maligna, as well as primary lesions at the following sites [92] :

  • Head
  • Neck
  • Hands
  • Feet
  • Pretibial surface
  • Nails
  • Ankles

For melanoma in situ, lentigo maligna type type, the AAD recommends permanent section analysis of the central MMS debulking specimen to identify and appropriately stage potential invasive cutaneous melanoma. If invasive cutaneous melanoma is identified on an MMS section intraoperatively, the tissue should be submitted for formal pathology review. [87]

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Wide Excision Surgical Margins

For wide excision of primary melanoma, the NCCN, AAD, and ESMO practice guidelines agree on the following surgical margin recommendations for primary melanoma [21, 87, 88]

  • Tumor in situ – Margin size 0.5-1.0 cm
  • Tumor ≤ 1 mm – Margin size 1 cm
  • Tumor > 1 to 2 mm – Margin size 1-2 cm
  • Tumor > 2 mm – Margin size 2 cm

The AAD guidelines note that margins may be narrower to accommodate function and/or anatomic location.However, for primary invasive melanomas at anatomically constrained sites (eg, head and neck, acral), margins of < 1 cm (by either wide excision or Mohs micrographic surgery) are generally not recommended until further studies are available. [87]

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Radiation Therapy

NCCN guidelines recommend consideration of radiation therapy in the following situations [21] :

  • Primary disease: As adjuvant treatment in selected patients with factors that include deep desmoplastic melanoma with narrow margins, extensive neurotropism, or locally recurrent disease

  • Regional disease: As adjuvant treatment following resection of category 2B nodes and LDH < 1.5 times the upper limit of normal, and extranodal tumor extension; as palliative treatment for unresectable disease

  • Metastatic disease: As either adjuvant or primary treatment for brain metastases

ESMO recommends considering stereotactic radiation of regional or single distant metastatic disease. [88]

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Treatment for Advanced Melanoma

NCCN recommendations for treatment of melanoma stage IV disease with distant metastasis include the following [21] :

  • Treatment depends on whether melanoma is limited (resectable) or disseminated (unresectable)
  • In limited disease, resection is recommended; alternatively, observation or systemic therapy may be chosen
  • Treatment for limited disease includes clinical trial enrollment or systemic therapy 
  • For patients with unresectable disease without brain metastases, treatment includes systemic therapy; patients with brain metastases require treatment of the central nervous disease

First-line immunotherapy regimens for systemic therapy (category 1), according to the NCCN guidelines, are as follows [21] :

  • Anti–PD-1 monotherapy: Pembrolizumab or nivolumab 
  • Nivolumab/ipilimumab 

If the tumor contains a BRAF V600 activating mutation, category 1 recommendations for first-line therapy are as follows [21] :

  • Dabrafenib plus trametinib
  • Vemurafenib plus cobimetinib
  • Encorafenib plus binimetinib 

Second-line or subsequent therapy recommendations are as follows [21] :

  • Anti PD-1 monotherapy: Pembrolizumab or nivolumab
  • Nivolumab/ipilimumab
  • Targeted therapy if a BRAF V600 activating mutation is present: Dabrafenib/trametinib or vemurafenib/cobimetinib
  • Ipilimumab
  • High-dose interleukin-2 (IL-2)
  • Cytotoxic agents
  • Imatinib for tumors with activating mutations of KIT 

 

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Follow-up for Melanoma Cancer Survivors

Follow-up guidelines from the National Comprehensive Cancer Network are listed below. [21]

Follow-up for stage 0 in situ is as follows:

  • At least annual skin examination for life

  • Educate patient in monthly self-examination of skin

Follow-up for stage IA is as follows:

  • History and physical examination (H&P), with emphasis on lymph nodes and skin, every 3-12 mo for 5 y, then annually as clinically indicated

  • At least annual skin examination for life

  • Educate patient in monthly self-examination of skin and lymph nodes

Follow-up for stage IB-IV (patients with no evidence of disease) is as follows:

  • H&P (with emphasis on nodes and skin) every 3-6 mo for 2 y, then every 3-12 mo for 2 y, then annually as clinically indicated

  • Chest radiography, lactate dehydrogenase (LDH) level, and complete blood cell count (CBC) every 6-12 mo (optional)

  • Routine imaging is not recommended for stage IB or IIA disease

  • Computed tomography (CT) scans to follow up for specific signs and symptoms

  • Consider CT and/or PET scans to screen stage IIB and higher for recurrent/metastatic disease every 3 to 12 months

  • At least annual skin examination for life

  • Educate patient in monthly self-examination of skin and lymph nodes

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