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Melanoma Management
Follow Up
- The purpose of follow-up is to detect recurrences and recognize new primary melanoma or additional skin tumors
- There is no existing consensus on the optimal frequency of follow-up for patients with melanoma at any stage
- However, it seems logical to tailor follow-up intervals based on individual risk
- Patients with the highest risk of recurrence or of developing new primary melanomas will need to be seen more frequently than those with lower risk, particularly in the 1st 2 years
- However, it seems logical to tailor follow-up intervals based on individual risk
- History and physical examination are significant components of follow-ups
- Recommended to be performed at least annually
- Comprehensive assessment of skin and lymph nodes is done; findings help direct further workup
- For Stage IA, follow-up is recommended 2-4 times within the 1st year post-treatment
- For Stage IB-IIB or IIC with negative sentinel lymph node biopsy, every 3 months follow-up is recommended within the 1st 3 years post-treatment, then every 6 months for the next 2 years up to 5 years
- Consider follow-up every 3 months for the 1st 3 years post-treatment, then every 6 months for the next 2 years up to 5 years for patients diagnosed with Stage IIC with no sentinel node biopsy or stage III melanoma
- For Stage IA-IIA NED, history and PE with emphasis on the regional nodes and skin should be performed every 6-12 months for 5 years, then annually as clinically indicated
- For Stage IIB-IV NED, history and PE should be performed every 3-6 months for 2 years, every 3-12 months for 3 years, then annually as clinically indicated
- Chest x-ray, CT scan, and/or PET/CT scans every 3-12 months, and cranial MRI annually may be requested to screen for metastasis/recurrence
- Routine surveillance lab tests and imaging studies in asymptomatic patients are generally not helpful and 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 and is the most accurate blood test for follow-up of patients
- Follow-up and 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 and/or radial phase of growth), may do re-excision of tumor and consider SLNB or lymphatic mapping
- Treatment recommendations should depend on stage of recurrence
- For local, satellite, and/or in-transit recurrence, treatment is as follows:
- For limited resectable disease, may consider complete excision, intralesional Talimogene laherparepvec (T-VEC), or systemic therapy, followed by adjuvant therapy with observation, checkpoint inhibitors Nivolumab or Pembrolizumab, BRAF inhibitors Dabrafenib/Trametinib, or Ipilimumab if previously given anti-PD1 therapy
- May consider SLNB during complete excisions
- For unresectable disease, systemic therapy local therapy with T-VEC, BCG or Interleukin-2, topical Imiquimod (for superficial dermal lesions), isolated limb perfusion/infusion with Melphalan, radiotherapy or palliative treatments such as limited excision and local ablation may be considered
- Subsequent adjuvant therapy using observation, clinical trial, or checkpoint inhibitors Nivolumab or Pembrolizumab, BRAF inhibitors Dabrafenib/Trametinib may also be considered
- For limited resectable disease, may consider complete excision, intralesional Talimogene laherparepvec (T-VEC), or systemic therapy, followed by adjuvant therapy with observation, checkpoint inhibitors Nivolumab or Pembrolizumab, BRAF inhibitors Dabrafenib/Trametinib, or Ipilimumab if previously given anti-PD1 therapy
- For nodal recurrence, treatment is as follows:
- Without prior dissection: May do CLND followed by adjuvant therapy with clinical trial, observation, checkpoint inhibitors Nivolumab or Pembrolizumab, BRAF inihibitors Dabrafenib/Trametinib, and Ipilimumab; consider radiation to nodal basin in selected patients
- Ipilimumab may be an option for patients who progress during anti-PD-1 therapy with resectable disease
- With prior dissection:
- If resectable, may do CLND then consider adjuvant therapy as above
- If incompletely resected, unresectable, or with systemic disease, consider clinical trial, systemic therapy, radiation, intralesional TVEC, and/or supportive care
- T-VEC was associated with a 16% response rate in highly selected patients with unresectable metastatic melanoma
- Without prior dissection: May do CLND followed by adjuvant therapy with clinical trial, observation, checkpoint inhibitors Nivolumab or Pembrolizumab, BRAF inihibitors Dabrafenib/Trametinib, and Ipilimumab; consider radiation to nodal basin in selected patients
