melanoma
MELANOMA
Melanoma is a skin neoplasm that originates from malignant transformation of melanocytes.
It commonly occurs in the extremities of women and on trunk or head and neck in men.
Metastases are via lymphatic and hematogenous routes.

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
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