Melanoma Management, Follow Up And Prevention

Management

Follow Up

The purpose of follow-up is to detect recurrences & recognize new primary melanoma or additional skin tumors
There is no existing consensus on the optimal frequency of follow-up for patients w/ melanoma at any stage
- However, it seems logical to tailor follow-up intervals based on individual risk
  - Patients w/ the highest risk of recurrence or of developing new primary melanomas will need to be seen more frequently than those w/ lower risk, particularly in the 1st 2 yr

History & physical examination are significant components of follow-ups
- Recommended to be performed at least annually
- Comprehensive assessment of skin & LNs is done; findings help direct further workup
- For Stage IA, follow-up is recommended 2-4 times w/in the 1st yr post-treatment
- For Stage IB-IIB or IIC w/ negative sentinel lymph node biopsy, every 3 mth follow-up is recommended w/in the 1st 3 yr post-treatment, then every 6 mth for the next 2 yr up to 5 yrs
- Consider follow-up every 3 mth for the 1st 3 yrs post-treatment, then every 6 mth for the next 2 yr up to 5 yr for patients diagnosed w/ Stage IIC w/ no sentinel node biopsy or stage III melanoma
- For Stage IA-IIA NED, history & PE w/ emphasis on the regional nodes & skin should be performed every 6-12 mth for 5 yr, then annually
- For Stage IIB-IV NED, history & PE should be performed every 3-6 mth for 2 yr, every 3-12 mth for 3 yr, then annually
  - Chest x-ray, CT scan, &/or PET/CT scans every 3-12 mth, & cranial MRI annually may be requested to screen for metastasis/recurrence

Routine surveillance lab tests & imaging studies in asymptomatic patients are generally not helpful & not recommended, though it may be used to check signs and symptoms
- May consider imaging studies in high-risk patients but its impact on survival has not been shown
- Consider ultrasound of regional LN when PE of LN is uncertain, in patients who were offered SLNB but did not undergo the procedure, in SLNB-positive patients who did not have CLND
- Serum LDH is an important survival predictor in stage IV disease, but serum S-100 has a higher disease progression specificity & is the most accurate blood test for follow-up of patients

Follow-up & additional workup of patients on adjuvant or palliative therapy should depend on the particular therapy prescribed

Recurrence

Type of recurrent disease is confirmed through biopsy or FNA; workup includes baseline imaging for staging
For persistent disease or true recurrence of local scar (indicated by positive in situ &/or radial phase of growth), may do re-excision of tumor & consider SLNB or lymphatic mapping
- Treatment recommendations should depend on stage of recurrence

For local, satellite, &/or in-transit recurrence, kindly refer to the Management of Stage III Melanoma algorithm for treatment recommendations
For nodal recurrence, treatment is as follows:
- W/o prior dissection: May do CLND followed by adjuvant therapy w/ clinical trial, observation or interferon alfa; consider radiation to nodal basin in selected patients
- W/ prior dissection:
  - If resectable, may do CLND then consider adjuvant therapy as above
  - If incompletely resected, unresectable, or w/ systemic disease, consider clinical trial, systemic therapy, radiation, or supportive care

Original New Drug Application Approvals by US FDA (1 - 15 December 2016)

15 Dec 2016

New drug applications approved by US FDA as of 1 - 15 December 2016 which includes New Molecular Entities (NMEs) and new biologics. It does not include Tentative Approvals. Supplemental approvals may have occurred since the original approval date.