More than 900 adults aged under 35 are diagnosed with melanoma annually in the UK. Here, we address areas where there is uncertainty or variation in practice and provide advice on managing vitamin D levels
More than 900 adults aged under 35 are diagnosed with melanoma annually in the UK. Here, we address areas where there is uncertainty or variation in practice and provide advice on managing vitamin D levels
- Consider a clinical margin of 0.5cm when excising stage 0 (in situ) melanoma.
- For stage I melanoma (<2mm thick) excise with at least 1cm margins.6
- For stage II melanoma (1.01–2mm thick if ulcerated or >2mm thick) excise with at least 2cm margins.7
- Consider CLND for people whose SLNB shows micrometastases. Discuss the advantages and disadvantages of CLND with the patient (Table 2)
- Offer therapeutic lymph node dissection to people with palpable stages IIIB–IIIC nodal melanoma or nodal disease detected by imaging. Do not offer adjuvant radiotherapy to patients with stage IIIA disease or to those with stage IIIB or IIIC melanoma unless a reduction in the risk of local recurrence is estimated to outweigh the risk of serious adverse effects.9
- Consider surgery or other ablative treatments (including stereotactic radiotherapy or radioembolisation) to prevent and control symptoms in consultation with the MDT. The MDT will also be the place to discuss those with brain metastases that may be suitable for surgery.10
- Consider dacarbazine for patients with stage IV metastatic melanoma if immunotherapy or targeted therapy is not suitable, but do not offer further cytotoxic chemotherapy in those previously treated with dacarbazine, except in the context of a clinical trial.11
- Patients with stage 0 melanoma (melanoma in situ) can be discharged after treatment.
- For stage IA melanoma, the recommendation is for 12 months follow-up and to discharge after that. No imaging should be undertaken.
- For stage IB–IIB or stage IIC with a negative SLNB, consider three-monthly follow-ups for the first three years and then six-monthly for the final two years. No imaging should be routinely undertaken as part of follow-up.
- For stage IIC melanoma but no SLNB or stage III (involved lymph nodes) melanoma, consider three-monthly follow-up for the first three years and then six-monthly for the final two years.
- Obviously, for stage IV melanoma patients, individualised follow-up is recommended.
- Cutaneous melanoma is the fifth most common cancer in the UK with over 13,000 cases being diagnosed in 2011, but its incidence continues to rise.
- The National Institute for Health and Care Excellence (NICE) in the UK has presented timely, updated guidance on the diagnosis and management of melanoma.
- As treatments are becoming more targeted, genetic testing of tumour samples for mutations (such as BRAF), which can determine the likelihood of clinical response to therapy, is becoming more important.
- The role of sentinel lymph node biopsy remains controversial.
- Centres will need to follow local guidance around vitamin D supplementation.
- National Institute for Health and Care Excellence. Melanoma: Assessment and Management. NG14. July 2015. www.nice.org.uk/guidance/ng14?unlid= (accessed July 2016).
- Vestergaard MEM. Dermoscopy compared with naked eye examination for the diagnosis of primary melanoma: A meta-analysis of studies performed in a clinical setting. Br J Dermatol 2008;159:669–76.
- Gandini S et al. Vitamin D and skin cancer: a meta-analysis. Eur J Cancer 2009;45(4):634–41.
- Edge S et al. American Joint Committee on Cancer ( AJCC). Cancer Staging Manual. 7th Edition 2010.
- Morton DL et al. Final trial report of sentinel-node biopsy versus nodal observation in melanoma. N Engl J Med 2014;370(7):599–609.
- Cohn-Cedermark G et al. Long term results of a randomized study by the Swedish Melanoma Study Group on 2-cm versus 5-cm resection margins for patients with cutaneous melanoma with a tumor thickness of 0.8-2.0mm. Cancer 2000;89:1495–501.
- Gilgren P et al. 2-cm versus 4-cm surgical excision margins for primary cutaneous melanoma thicker than 2mm: a randomised, multicentre trial. Lancet 2011;378:1635–42.
- van der Ploeg APT. Prognosis in patients with sentinel node-positive melanoma without immediate completion lymph node dissection. Br J Surg 2012;99;10:1396–405.
- Burmeister BH et al. Adjuvant radiotherapy versus observation alone for patients at risk of lymph node field relapse after therapeutic lymphadanectomy for melanoma: a randomised trial. Lancet Oncol 2012;13:589–97.
- Dyer MA et al. The role of whole brain radiation therapy in the management of melanoma brain metastases. J Radiat Oncol 2014;9:143.
- Patel PM et al. Extended schedule, escalated dose temozolomide versus dacarbazine in stage IV melanoma: Final results of a randomised phase III study (EORTC 18032) Eur J Cancer 2011;47:1476–83.
- Garbe C et al. Prospective evaluation of a follow-up schedule in cutaneous melanoma patients: recommendations for an effective follow-up strategy J Clin Onc 2003;21;3:520–9.
- Rueth NM et al. Is surveillance imaging effective for detecting surgically treatable recurrences in patients with melanoma? A comparative analysis of stage-specific surveillance strategies. Ann Surg 2014;259(6):1215–22.