Treatment

Gold standard — surgical

Wide local excision (WLE)

In situ

  • 0.5—1 cm margins
  • If head / neck melanoma — consider Mohs ± postoperative topical imiquimod

T1 (Thickness <1mm)

  • 1 cm margins

T2 (Thickness 1.01—2mm)

  • 1—2 cm margins

T3 / T4 (Thickness >2mm)

  • 2 cm margins

Acral and head and neck melanoma → preservation of function is prioritized if possible and oncologically appropriate

  • WLE as above + complete lymph node dissection if lymph nodes OR metastatectomy if respectable in transit or satellite lesions + consider adjuvant treatment
  • If unresectable — adjuvant therapy, radiation, regional chemotherapy or intralesional treatment to be discussed in tumor board
Adjuvant therapy after curative surgery for patients at high risk of recurrence
  • if BRAF negative, 1 year immunotherapy (e.g. nivolumab, pembrolizumab, clinical trial)
  • if BRAF positive, either 1 year immunotherapy OR BRAF+MEK inhibitor combination

  • Metastatectomy if resectable disease may provide durable response
  • If BRAF+ → either immunotherapy single agent or combo (PD1 + CTLA4 inhibitors) OR MEK and BRAF inhibitor combination
  • Patients may be candidates into clinical trials of other agents (e.g. imatinib)
Local recurrence

Recurrence ≤ 2cm of excisional scar. No survival difference if:

  • Promptly re-excised
  • No distant disease
  • Restaging and treatment as per clinical stage

Lifelong follow-up due to:

  1. Risk of other primary skin melanoma: 3.5—4.5%
  2. Risk of local recurrence 4%; higher: 2—5 years, ulcerated, thicker, head, neck, distal legs
  3. Risk of ultra-late recurrence (>15 years) hard to predict
  4. Higher risk of other cutaneous and non-cutaneous cancer
  5. Early detection of regional lymph nodes and in-transit lesions affects prognosis
  6. Distant metastases: early surgical resection prolongs survival

Note: 90% of recurrences happen within 5 years after primary diagnosis.

Sun protection, self-skin exam, oral Vitamin D, screening of family members

TBSE, lymph node examination, review of systems
  • Stage 0:-IIA: every 3-6 months (2 years), then annual
  • Stage IIB and above: every 3 months for 2—3 years, then every 6—12 months for life
Imaging
  • Stage IIB and above: pan-CT or PET-CT every 3—6 months (2—3 years), then every 6—12 months for 5 years, then symptomatic only
  • Regional lymph node ultrasound if positive SLNB without complete lymph node dissection
  • Brain imaging if symptomatic

Also: Sun protection, self-skin exam, oral Vitamin D, screening of family members.