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.

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
  • 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
    • 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 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, and BRAF inihibitors Dabrafenib/Trametinib; consider radiation to nodal basin in selected patients
    • 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, or supportive care
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