Summary of recommendations

From Cancer Guidelines Wiki


This page provides a summary of the recommendations of the completed Melanoma guidelines contents. Other sections of the guidelines are currently in progress and will be published iteratively.

For explanation of the different types of recommendations, see below.

You may also like to refer to the Guideline development process for details on the levels of evidence and recommendation grades.

Recommendations

What are the clinical features of melanoma and how do atypical melanomas present?

Practice pointQuestion mark transparent.png

Melanomas are generally distinguished from benign lesions by their history of change and thick melanomas often do not conform to the ‘ABCD’ rule, but are Elevated, Firm and Growing. Therefore, careful history taking is important and any lesion that continues to grow or change in size, shape, colour or elevation over a period of more than one month should be biopsied and assessed histologically or referred for expert opinion.

  • Clinical_question:What are the clinical features of an atypical melanoma?#Practice_point_1
  • Melanomas are generally distinguished from benign lesions by their history of change and thick melanomas often do not conform to the ‘ABCD’ rule, but are Elevated, Firm and Growing. Therefore, careful history taking is important and any lesion that continues to grow or change in size, shape, colour or elevation over a period of more than one month should be biopsied and assessed histologically or referred for expert opinion.
  • Good practice point
Practice pointQuestion mark transparent.png

Suspicious raised lesions should be excised and not monitored.

  • Clinical_question:What are the clinical features of an atypical melanoma?#Practice_point_2
  • Suspicious raised lesions should be excised and not monitored.
  • Good practice point

Back to top

What type of biopsy should be performed for a suspicious pigmented skin lesion?

Evidence-based recommendationQuestion mark transparent.png Grade
The optimal biopsy approach for a suspicious pigmented lesion is complete excision with a 2 mm clinical margin and upper subcutis.
C
  • Clinical_question:What type of biopsy should be performed for a suspicious pigmented skin lesion?#Recommendation_1
  • The optimal biopsy approach for a suspicious pigmented lesion is complete excision with a 2 mm clinical margin and upper subcutis.
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
Partial biopsies may not be fully representative of the lesion and need to be interpreted with caution and in light of the clinical findings to minimise incorrect false negative diagnoses and understaging.
C
  • Clinical_question:What type of biopsy should be performed for a suspicious pigmented skin lesion?#Recommendation_2
  • Partial biopsies may not be fully representative of the lesion and need to be interpreted with caution and in light of the clinical findings to minimise incorrect false negative diagnoses and understaging.
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
In carefully selected clinical circumstances (such as large in situ lesions, large facial or acral lesions or where the suspicion of melanoma is low) and in the hands of experienced clinicians, partial incisional, punch or shave biopsies may be appropriate.
C
  • Clinical_question:What type of biopsy should be performed for a suspicious pigmented skin lesion?#Recommendation_3
  • In carefully selected clinical circumstances (such as large in situ lesions, large facial or acral lesions or where the suspicion of melanoma is low) and in the hands of experienced clinicians, partial incisional, punch or shave biopsies may be appropriate.
  • Recommendation
Practice pointQuestion mark transparent.png

It is advisable to discuss unexpected pathology results with the reporting pathologist.

  • Clinical_question:What type of biopsy should be performed for a suspicious pigmented skin lesion?#Practice_point_1
  • It is advisable to discuss unexpected pathology results with the reporting pathologist.
  • Good practice point
Practice pointQuestion mark transparent.png

Punch biopsy should not be utilised for the routine diagnosis of suspected melanoma because this technique is associated with high rates of histopathological incorrect false negative diagnosis. Where a punch biopsy has been used for the diagnosis of a suspected BCC or SCC, and the diagnosis has been found to be melanocytic, then consideration should be given to excision of the entire lesion.

  • Clinical_question:What type of biopsy should be performed for a suspicious pigmented skin lesion?#Practice_point_2
  • Punch biopsy should not be utilised for the routine diagnosis of suspected melanoma because this technique is associated with high rates of histopathological incorrect false negative diagnosis. Where a punch biopsy has been used for the diagnosis of a suspected BCC or SCC, and the diagnosis has been found to be melanocytic, then consideration should be given to excision of the entire lesion.
  • Good practice point
Practice pointQuestion mark transparent.png

The use of deep shave excision (saucerisation) should be limited to in situ or superficially invasive melanomas to preserve prognostic features and optimise accurate planning of therapy.

  • Clinical_question:What type of biopsy should be performed for a suspicious pigmented skin lesion?#Practice_point_3
  • The use of deep shave excision (saucerisation) should be limited to in situ or superficially invasive melanomas to preserve prognostic features and optimise accurate planning of therapy.
  • Good practice point

Back to top

When is a sentinel node biopsy indicated?

Evidence-based recommendationQuestion mark transparent.png Grade
Sentinel lymph node biopsy should be considered for all patients with melanoma greater than 1 mm in thickness and for patients with melanoma greater than 0.75 mm with other high risk pathological features to provide optimal staging and prognostic information and to maximise management options for patients who are node positive.
B
  • Clinical_question:When is a sentinel node biopsy indicated?#Recommendation_1
  • Sentinel lymph node biopsy should be considered for all patients with melanoma greater than 1 mm in thickness and for patients with melanoma greater than 0.75 mm with other high risk pathological features to provide optimal staging and prognostic information and to maximise management options for patients who are node positive.
  • Recommendation
Practice pointQuestion mark transparent.png

Sentinel lymph node biopsy (SLNB) should be performed at the time of the primary wide excision.

  • Clinical_question:When is a sentinel node biopsy indicated?#Practice_point_1
  • Sentinel lymph node biopsy (SLNB) should be performed at the time of the primary wide excision.
  • Good practice point
Practice pointQuestion mark transparent.png

Sentinel lymph node biopsy (SLNB) should be performed in a centre with expertise in the procedure, including nuclear medicine, surgery and pathology to optimise the accuracy of the test.

  • Clinical_question:When is a sentinel node biopsy indicated?#Practice_point_2
  • Sentinel lymph node biopsy (SLNB) should be performed in a centre with expertise in the procedure, including nuclear medicine, surgery and pathology to optimise the accuracy of the test.
  • Good practice point
Practice pointQuestion mark transparent.png

Patients being considered for sentinel lymph node biopsy (SLNB) should be given an opportunity to fully discuss the risks and benefits with a clinician who performs this procedure.

  • Clinical_question:When is a sentinel node biopsy indicated?#Practice_point_3
  • Patients being considered for sentinel lymph node biopsy (SLNB) should be given an opportunity to fully discuss the risks and benefits with a clinician who performs this procedure.
  • Good practice point
Practice pointQuestion mark transparent.png

A consideration of sentinel lymph node biopsy (SLNB) forms an important part of the multidisciplinary management of patients with clinically node negative cutaneous melanoma.

  • Clinical_question:When is a sentinel node biopsy indicated?#Practice_point_4
  • A consideration of sentinel lymph node biopsy (SLNB) forms an important part of the multidisciplinary management of patients with clinically node negative cutaneous melanoma.
  • Good practice point
Practice pointQuestion mark transparent.png

Sentinel lymph node biopsy provides accurate staging of the lymph node basin by presenting a high-yield, low volume tissue sample for histopathological assessment. Not surprisingly, there is an increased rate of detection of micrometastatic disease when increasing numbers of sections are evaluated pathologically including when supplemented by immunohistochemistry for melanoma associated antigens. However there is no consensus as to the optimal number of sections that should be examined, the levels at which they should be cut from the paraffin block and which immunostains should be utilised.

  • Clinical_question:When is a sentinel node biopsy indicated?#Practice_point_5
  • Sentinel lymph node biopsy provides accurate staging of the lymph node basin by presenting a high-yield, low volume tissue sample for histopathological assessment. Not surprisingly, there is an increased rate of detection of micrometastatic disease when increasing numbers of sections are evaluated pathologically including when supplemented by immunohistochemistry for melanoma associated antigens. However there is no consensus as to the optimal number of sections that should be examined, the levels at which they should be cut from the paraffin block and which immunostains should be utilised.
  • Good practice point
Practice pointQuestion mark transparent.png

Sentinel lymph nodes (SLNs) should be removed intact, preferably with a thin rim of surrounding adipose tissue and be devoid of crush or diathermy artefacts that may complicate pathological assessment. The pathology request form should indicate the number of removed SLNs and their anatomical locations and the specimens clearly labelled. Any “second tier” lymph nodes or non-SLNs that have also been removed should be indicated as such on the request form and the specimens clearly labelled. The pathologist should slice the SLN using either the bivalving procedure along its longitudinal axis through the median plane or cut the SLN into multiple transverse slices using the “bread loaf” technique to make available the largest cut surface area of lymph node tissue for pathological examination. To identify low volume metastases, pathologists should examine multiple haematoxylin-eosin and immunohistochemically-stained sections from each SLN. Sections from each slice of all SLNs should be stained with both H&E and immunohistochemistry for melanoma associated antigens. HMB-45, S100, SOX10, Melan A and tyrosinase have all been utilised as immunohistochemical stains. As per AJCC guidelines, in patients with positive SNs, the single largest maximum dimension (measured in millimeters to the nearest 0.1 mm using an ocular micrometer) of the largest discrete metastatic melanoma deposit should be recorded in the pathology report. Routine frozen section examination of SNs from melanoma patients is not recommended.

  • Clinical_question:When is a sentinel node biopsy indicated?#Practice_point_6
  • Sentinel lymph nodes (SLNs) should be removed intact, preferably with a thin rim of surrounding adipose tissue and be devoid of crush or diathermy artefacts that may complicate pathological assessment. The pathology request form should indicate the number of removed SLNs and their anatomical locations and the specimens clearly labelled. Any “second tier” lymph nodes or non-SLNs that have also been removed should be indicated as such on the request form and the specimens clearly labelled. The pathologist should slice the SLN using either the bivalving procedure along its longitudinal axis through the median plane or cut the SLN into multiple transverse slices using the “bread loaf” technique to make available the largest cut surface area of lymph node tissue for pathological examination. To identify low volume metastases, pathologists should examine multiple haematoxylin-eosin and immunohistochemically-stained sections from each SLN. Sections from each slice of all SLNs should be stained with both H&E and immunohistochemistry for melanoma associated antigens. HMB-45, S100, SOX10, Melan A and tyrosinase have all been utilised as immunohistochemical stains. As per AJCC guidelines, in patients with positive SNs, the single largest maximum dimension (measured in millimeters to the nearest 0.1 mm using an ocular micrometer) of the largest discrete metastatic melanoma deposit should be recorded in the pathology report. Routine frozen section examination of SNs from melanoma patients is not recommended.
  • Good practice point

Back to top

What are the recommended safety margins for radical excision of primary melanoma?/In Situ

Evidence-based recommendationQuestion mark transparent.png Grade
After initial excision biopsy, the radial excision margins, measured clinically from the edge of the melanoma, should be 5-10 mm (measured with good lighting and magnification) with the aim of achieving complete histological clearance.

Melanoma in situ of non-lentigo maligna type is likely to be completely excised with 5mm margins whereas lentigo maligna may require wider excision. Minimum clearances from all margins should be stated/assessed. Consideration should be given to further excision if necessary; positive histological margins are unacceptable.

D
  • Clinical_question:What are the recommended safety margins for radical excision of primary melanoma?/In situ#Recommendation_1
  • After initial excision biopsy, the radial excision margins, measured clinically from the edge of the melanoma, should be 5-10 mm (measured with good lighting and magnification) with the aim of achieving complete histological clearance.

Melanoma in situ of non-lentigo maligna type is likely to be completely excised with 5mm margins whereas lentigo maligna may require wider excision. Minimum clearances from all margins should be stated/assessed. Consideration should be given to further excision if necessary; positive histological margins are unacceptable.

  • Recommendation
Practice pointQuestion mark transparent.png

Excisions should have vertical edges to ensure consistent margins.

  • Clinical_question:What are the recommended safety margins for radical excision of primary melanoma?/In situ#Practice_point_1
  • Excisions should have vertical edges to ensure consistent margins.
  • Good practice point
Practice pointQuestion mark transparent.png

For all melanomas, minimum clearances from all margins should be stated/assessed. When necessary, further excision should be performed in order to achieve the appropriate margin of clearance.

  • Clinical_question:What are the recommended safety margins for radical excision of primary melanoma?/In situ#Practice_point_2
  • For all melanomas, minimum clearances from all margins should be stated/assessed. When necessary, further excision should be performed in order to achieve the appropriate margin of clearance.
  • Good practice point
Practice pointQuestion mark transparent.png

Excision biopsy of the complete lesion with a narrow (2mm) margin is appropriate for definitive diagnosis of primary melanoma. Once the diagnosis of melanoma has been made, re-excision of the lesion (biopsy site) should then be performed in order to achieve the definitive, wider margins that are recommended in these guidelines.

  • Clinical_question:What are the recommended safety margins for radical excision of primary melanoma?/In situ#Practice_point_3
  • Excision biopsy of the complete lesion with a narrow (2mm) margin is appropriate for definitive diagnosis of primary melanoma. Once the diagnosis of melanoma has been made, re-excision of the lesion (biopsy site) should then be performed in order to achieve the definitive, wider margins that are recommended in these guidelines.
  • Good practice point
Practice pointQuestion mark transparent.png

Depth of excision in usual clinical practice is excision down to but not including the deep fascia unless it is involved or has been reached during the diagnostic excision. For body sites where there is particularly deep subcutis, it is usual practice to excise to a depth equal to the recommended lateral (radial) excision margins for that specific melanoma; in these cases it is not deemed necessary to excise right down to fascia.

  • Clinical_question:What are the recommended safety margins for radical excision of primary melanoma?/In situ#Practice_point_4
  • Depth of excision in usual clinical practice is excision down to but not including the deep fascia unless it is involved or has been reached during the diagnostic excision. For body sites where there is particularly deep subcutis, it is usual practice to excise to a depth equal to the recommended lateral (radial) excision margins for that specific melanoma; in these cases it is not deemed necessary to excise right down to fascia.
  • Good practice point
Practice pointQuestion mark transparent.png

Where tissue flexibility is limited, a flap repair or skin graft may be necessary subsequent to an adequate margin of removal.

  • Clinical_question:What are the recommended safety margins for radical excision of primary melanoma?/In situ#Practice_point_5
  • Where tissue flexibility is limited, a flap repair or skin graft may be necessary subsequent to an adequate margin of removal.
  • Good practice point
Practice pointQuestion mark transparent.png

Most primary melanomas can be treated as an outpatient under local anaesthesia or as a day-case.

  • Clinical_question:What are the recommended safety margins for radical excision of primary melanoma?/In situ#Practice_point_6
  • Most primary melanomas can be treated as an outpatient under local anaesthesia or as a day-case.
  • Good practice point
Practice pointQuestion mark transparent.png

Patients should be informed that surgical excision may be followed by wound infection, bleeding, haematoma, failure of the skin graft or flap, risk of numbness, a non-cosmetic scar, dehiscence and the possibility of further surgery.

  • Clinical_question:What are the recommended safety margins for radical excision of primary melanoma?/In situ#Practice_point_7
  • Patients should be informed that surgical excision may be followed by wound infection, bleeding, haematoma, failure of the skin graft or flap, risk of numbness, a non-cosmetic scar, dehiscence and the possibility of further surgery.
  • Good practice point
Practice pointQuestion mark transparent.png

Some tumours may be incompletely excised despite using the above-recommended margins. These include melanomas occurring in severely sun-damaged skin (e.g. LM) and those with difficult-to-define margins (eg amelanotic and desmoplastic melanomas). In these categories, the presence of atypical melanocytes at the margins of excision should be detected by comprehensive histological examination (including immunohistochemical staining) and followed by wider excision as appropriate. Alternatively, staged serial excision (also known as ‘slow Mohs’ surgery) may be utilised to achieve complete histological clearance of melanoma in situ/lentigo maligna. Pre-operative mapping of the extent of some lesions with confocal microscopy may be useful and is available in some centres. Referral to a specialist melanoma centre or discussion in a multidisciplinary meeting should be considered for difficult or complicated cases.

  • Clinical_question:What are the recommended safety margins for radical excision of primary melanoma?/In situ#Practice_point_8
  • Some tumours may be incompletely excised despite using the above-recommended margins. These include melanomas occurring in severely sun-damaged skin (e.g. LM) and those with difficult-to-define margins (eg amelanotic and desmoplastic melanomas). In these categories, the presence of atypical melanocytes at the margins of excision should be detected by comprehensive histological examination (including immunohistochemical staining) and followed by wider excision as appropriate. Alternatively, staged serial excision (also known as ‘slow Mohs’ surgery) may be utilised to achieve complete histological clearance of melanoma in situ/lentigo maligna. Pre-operative mapping of the extent of some lesions with confocal microscopy may be useful and is available in some centres.

Referral to a specialist melanoma centre or discussion in a multidisciplinary meeting should be considered for difficult or complicated cases.

  • Good practice point
Practice pointQuestion mark transparent.png

Amelanotic melanoma can present significant difficulties for defining a margin with up to one third of subungual and nodular melanomas being non-pigmented. This may dictate choice of a wider margin, or further re-excision, where practicable.

  • Clinical_question:What are the recommended safety margins for radical excision of primary melanoma?/In situ#Practice_point_9
  • Amelanotic melanoma can present significant difficulties for defining a margin with up to one third of subungual and nodular melanomas being non-pigmented. This may dictate choice of a wider margin, or further re-excision, where practicable.
  • Good practice point

Back to top

What are the recommended safety margins for radical excision of primary melanoma?

Evidence-based recommendationQuestion mark transparent.png Grade
(pT1) melanoma < 1.0 mm
After initial excision biopsy, the radial excision margins, measured clinically from the edge of the melanoma, should be 1 cm. Minimum clearances from all margins should be stated/assessed. Consideration should be given to further excision if necessary; positive histological margins are unacceptable.
B
  • Clinical_question:What are the recommended safety margins for radical excision of primary melanoma?/Invasive melanoma#Recommendation_1
  • (pT1) melanoma < 1.0 mm
    After initial excision biopsy, the radial excision margins, measured clinically from the edge of the melanoma, should be 1 cm. Minimum clearances from all margins should be stated/assessed. Consideration should be given to further excision if necessary; positive histological margins are unacceptable.
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
(pT2) melanoma 1.01 mm–2.00 mm
After initial excision biopsy, the radial excision margins, measured clinically from the edge of the melanoma, should be 1–2 cm. Minimum clearances from all margins should be stated/assessed. Consideration should be given to further excision if necessary; positive histological margins are unacceptable.
B
  • Clinical_question:What are the recommended safety margins for radical excision of primary melanoma?/Invasive melanoma#Recommendation_2
  • (pT2) melanoma 1.01 mm–2.00 mm
    After initial excision biopsy, the radial excision margins, measured clinically from the edge of the melanoma, should be 1–2 cm. Minimum clearances from all margins should be stated/assessed. Consideration should be given to further excision if necessary; positive histological margins are unacceptable.
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
(pT3) melanoma 2.01 mm–4.00 mm
After initial excision biopsy, the radial excision margins, measured clinically from the edge of the melanoma, should be 1–2 cm. Minimum clearances from all margins should be stated/assessed. Consideration should be given to further excision if necessary; positive histological margins are unacceptable.

Caution should be exercised for melanomas 2.01–4.00 mm thick, especially with adverse prognostic factors, because evidence concerning optimal excision margins is unclear. Where possible, it may be desirable to take a wider margin (2 cm) for these tumours depending on the tumour site and characteristics, and prevailing surgeon/patient preferences.

B
  • Clinical_question:What are the recommended safety margins for radical excision of primary melanoma?/Invasive melanoma#Recommendation_3
  • (pT3) melanoma 2.01 mm–4.00 mm
    After initial excision biopsy, the radial excision margins, measured clinically from the edge of the melanoma, should be 1–2 cm. Minimum clearances from all margins should be stated/assessed. Consideration should be given to further excision if necessary; positive histological margins are unacceptable.

Caution should be exercised for melanomas 2.01–4.00 mm thick, especially with adverse prognostic factors, because evidence concerning optimal excision margins is unclear. Where possible, it may be desirable to take a wider margin (2 cm) for these tumours depending on the tumour site and characteristics, and prevailing surgeon/patient preferences.

  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
(pT4) melanoma > 4.0 mm
After initial excision biopsy, the radial excision margins, measured clinically from the edge of the melanoma, should be 2 cm. Minimum clearances from all margins should be stated/assessed. Consideration should be given to further excision if necessary; positive histological margins are unacceptable.
B
  • Clinical_question:What are the recommended safety margins for radical excision of primary melanoma?/Invasive melanoma#Recommendation_4
  • (pT4) melanoma > 4.0 mm
    After initial excision biopsy, the radial excision margins, measured clinically from the edge of the melanoma, should be 2 cm. Minimum clearances from all margins should be stated/assessed. Consideration should be given to further excision if necessary; positive histological margins are unacceptable.
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
Acral lentiginous and subungual melanoma are usually treated with a minimum margin as set out above, where practicable, including partial digital amputation usually incorporating the joint immediately proximal to the melanoma.
D
  • Clinical_question:What are the recommended safety margins for radical excision of primary melanoma?/Invasive melanoma#Recommendation_5
  • Acral lentiginous and subungual melanoma are usually treated with a minimum margin as set out above, where practicable, including partial digital amputation usually incorporating the joint immediately proximal to the melanoma.
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
Excision margins might be modified to accommodate individual anatomic sites or functional considerations, but this practice would be based solely on case-series information, and individual factors, rather than RCT evidence which is currently lacking.
D
  • Clinical_question:What are the recommended safety margins for radical excision of primary melanoma?/Invasive melanoma#Recommendation_6
  • Excision margins might be modified to accommodate individual anatomic sites or functional considerations, but this practice would be based solely on case-series information, and individual factors, rather than RCT evidence which is currently lacking.
  • Recommendation
Practice pointQuestion mark transparent.png

Excisions should have vertical edges to ensure consistent margins.

  • Clinical_question:What are the recommended safety margins for radical excision of primary melanoma?/Invasive melanoma#Practice_point_1
  • Excisions should have vertical edges to ensure consistent margins.
  • Good practice point
Practice pointQuestion mark transparent.png

For all melanomas, minimum clearances from all margins should be stated/assessed. Consideration should be given to further excision if necessary because positive histological margins are unacceptable.

  • Clinical_question:What are the recommended safety margins for radical excision of primary melanoma?/Invasive melanoma#Practice_point_2
  • For all melanomas, minimum clearances from all margins should be stated/assessed. Consideration should be given to further excision if necessary because positive histological margins are unacceptable.
  • Good practice point
Practice pointQuestion mark transparent.png

Excision biopsy of the complete lesion with a narrow (2mm) margin is appropriate for the definitive diagnosis of primary melanoma. Once the diagnosis of melanoma has been made, re-excision of the lesion (biopsy site) should then be performed in order to achieve the definitive, wider margins that are recommended in these guidelines.

  • Clinical_question:What are the recommended safety margins for radical excision of primary melanoma?/Invasive melanoma#Practice_point_3
  • Excision biopsy of the complete lesion with a narrow (2mm) margin is appropriate for the definitive diagnosis of primary melanoma. Once the diagnosis of melanoma has been made, re-excision of the lesion (biopsy site) should then be performed in order to achieve the definitive, wider margins that are recommended in these guidelines.
  • Good practice point
Practice pointQuestion mark transparent.png

Depth of excision in usual clinical practice is excision down to but not including the deep fascia unless it is involved or has been reached during the diagnostic excision. For body sites where there is particularly deep subcutis, it is usual practice to excise to a depth equal to the recommended lateral (radial) excision margins for that specific melanoma; in these cases it is not deemed necessary to excise right down to fascia.

  • Clinical_question:What are the recommended safety margins for radical excision of primary melanoma?/Invasive melanoma#Practice_point_4
  • Depth of excision in usual clinical practice is excision down to but not including the deep fascia unless it is involved or has been reached during the diagnostic excision. For body sites where there is particularly deep subcutis, it is usual practice to excise to a depth equal to the recommended lateral (radial) excision margins for that specific melanoma; in these cases it is not deemed necessary to excise right down to fascia.
  • Good practice point
Practice pointQuestion mark transparent.png

Where tissue flexibility is limited, a flap repair or skin graft is often necessary subsequent to an adequate margin of removal.

  • Clinical_question:What are the recommended safety margins for radical excision of primary melanoma?/Invasive melanoma#Practice_point_5
  • Where tissue flexibility is limited, a flap repair or skin graft is often necessary subsequent to an adequate margin of removal.
  • Good practice point
Practice pointQuestion mark transparent.png

Most primary melanomas can be treated as an outpatient under local anaesthesia or as a day-case.

  • Clinical_question:What are the recommended safety margins for radical excision of primary melanoma?/Invasive melanoma#Practice_point_6
  • Most primary melanomas can be treated as an outpatient under local anaesthesia or as a day-case.
  • Good practice point
Practice pointQuestion mark transparent.png

Patients should be informed that surgical excision may be followed by wound infection, bleeding, haematoma, failure of the skin graft or flap, risk of numbness, a non-cosmetic scar, dehiscence and the possibility of further surgery.

  • Clinical_question:What are the recommended safety margins for radical excision of primary melanoma?/Invasive melanoma#Practice_point_7
  • Patients should be informed that surgical excision may be followed by wound infection, bleeding, haematoma, failure of the skin graft or flap, risk of numbness, a non-cosmetic scar, dehiscence and the possibility of further surgery.
  • Good practice point
Practice pointQuestion mark transparent.png

Some tumours may be incompletely excised despite using the above-recommended margins. These include melanomas occurring in severely sun-damaged skin (e.g. lentigo maligna) and those with difficult-to-define margins (e.g. amelanotic and desmoplastic melanomas). In these categories, the presence of atypical melanocytes at the margins of excision should be detected by comprehensive histological examination (including immunohistochemical staining) and followed by wider excision.

  • Clinical_question:What are the recommended safety margins for radical excision of primary melanoma?/Invasive melanoma#Practice_point_8
  • Some tumours may be incompletely excised despite using the above-recommended margins. These include melanomas occurring in severely sun-damaged skin (e.g. lentigo maligna) and those with difficult-to-define margins (e.g. amelanotic and desmoplastic melanomas). In these categories, the presence of atypical melanocytes at the margins of excision should be detected by comprehensive histological examination (including immunohistochemical staining) and followed by wider excision.
  • Good practice point
Practice pointQuestion mark transparent.png

Amelanotic melanoma can present significant difficulties for defining a margin with up to one third of subungual and nodular melanomas being non-pigmented. This may dictate choice of a wider margin, or further re-excision, where practicable.

  • Clinical_question:What are the recommended safety margins for radical excision of primary melanoma?/Invasive melanoma#Practice_point_9
  • Amelanotic melanoma can present significant difficulties for defining a margin with up to one third of subungual and nodular melanomas being non-pigmented. This may dictate choice of a wider margin, or further re-excision, where practicable.
  • Good practice point
Practice pointQuestion mark transparent.png

For patients with deeper invasive melanomas (> 1 mm thick), referral to a specialised melanoma centre or discussion in a multidisciplinary meeting should be considered to ensure that best practice is implemented and for the collection of national outcome data. This may present logistic difficulties in regional and remote areas, but input from a specialist melanoma centre.

  • Clinical_question:What are the recommended safety margins for radical excision of primary melanoma?/Invasive melanoma#Practice_point_10
  • For patients with deeper invasive melanomas (> 1 mm thick), referral to a specialised melanoma centre or discussion in a multidisciplinary meeting should be considered to ensure that best practice is implemented and for the collection of national outcome data. This may present logistic difficulties in regional and remote areas, but input from a specialist melanoma centre.
  • Good practice point

Back to top

What is the role of dermoscopy in melanoma diagnosis?

Practice pointQuestion mark transparent.png

Dermoscopy can also identify diagnostic features in non-pigmented (amelanotic) lesions.

  • Clinical_question:What is the role of dermoscopy in melanoma diagnosis?#Practice_point_1
  • Dermoscopy can also identify diagnostic features in non-pigmented (amelanotic) lesions.
  • Good practice point
Evidence-based recommendationQuestion mark transparent.png Grade
Clinicians who are performing skin examinations for the purpose of detecting skin cancer should be trained in and use dermoscopy.
A
  • Clinical_question:What is the role of dermoscopy in melanoma diagnosis?#Recommendation_1
  • Clinicians who are performing skin examinations for the purpose of detecting skin cancer should be trained in and use dermoscopy.
  • Recommendation

Back to top

What is the role of sequential digital dermoscopy imaging in melanoma diagnosis?

Practice pointQuestion mark transparent.png

Only flat or slightly raised lesions should undergo dermoscopy monitoring. Nodular lesions should not be monitored.

  • Clinical_question:What is the role of sequential digital dermoscopy imaging in melanoma diagnosis?#Practice_point_1
  • Only flat or slightly raised lesions should undergo dermoscopy monitoring. Nodular lesions should not be monitored.
  • Good practice point
Practice pointQuestion mark transparent.png

The interval for short-term monitoring is 3 months where any change leads to excision. Where lentigo maligna is in the differential diagnosis it is recommended an additional 3 months of monitoring performed, i.e. total of 6 months.

  • Clinical_question:What is the role of sequential digital dermoscopy imaging in melanoma diagnosis?#Practice_point_2
  • The interval for short-term monitoring is 3 months where any change leads to excision. Where lentigo maligna is in the differential diagnosis it is recommended an additional 3 months of monitoring performed, i.e. total of 6 months.
  • Good practice point
Practice pointQuestion mark transparent.png

The usual interval for long-term monitoring is 6-12 months. Unlike short-term monitoring, certain specific changes are required for excision to be indicated.

  • Clinical_question:What is the role of sequential digital dermoscopy imaging in melanoma diagnosis?#Practice_point_3
  • The usual interval for long-term monitoring is 6-12 months. Unlike short-term monitoring, certain specific changes are required for excision to be indicated.
  • Good practice point
Evidence-based recommendationQuestion mark transparent.png Grade
To assess individual melanocytic lesions of concern, recommend the use of short-term sequential digital dermoscopy imaging (dermoscopy monitoring) to detect melanomas that lack dermoscopic features of melanoma.
B
  • Clinical_question:What is the role of sequential digital dermoscopy imaging in melanoma diagnosis?#Recommendation_1
  • To assess individual melanocytic lesions of concern, recommend the use of short-term sequential digital dermoscopy imaging (dermoscopy monitoring) to detect melanomas that lack dermoscopic features of melanoma.
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
To assess individual or multiple melanocytic lesions in routine surveillance of high risk patients, recommend the use of long-term sequential digital dermoscopy imaging (dermoscopy monitoring) to detect melanomas that lack dermoscopic features of melanoma.
B
  • Clinical_question:What is the role of sequential digital dermoscopy imaging in melanoma diagnosis?#Recommendation_2
  • To assess individual or multiple melanocytic lesions in routine surveillance of high risk patients, recommend the use of long-term sequential digital dermoscopy imaging (dermoscopy monitoring) to detect melanomas that lack dermoscopic features of melanoma.
  • Recommendation

Back to top

What is the role of automated instruments in melanoma diagnosis?

Evidence-based recommendationQuestion mark transparent.png Grade
There is insufficient evidence to recommend the routine use of automated instruments for the clinical diagnosis of primary melanoma. However, particularly when a benign measurement is found using the cited protocols of Nevisense™ and MelaFind™, this information may aid the clinician.
D
  • Clinical_question:What is the role of automated instruments in melanoma diagnosis?#Recommendation_1
  • There is insufficient evidence to recommend the routine use of automated instruments for the clinical diagnosis of primary melanoma. However, particularly when a benign measurement is found using the cited protocols of Nevisense™ and MelaFind™, this information may aid the clinician.
  • Recommendation

Back to top

What is the appropriate treatment for macroscopic (i.e. detectable clinically or by ultrasound) nodal metastasis?

Practice pointQuestion mark transparent.png

Patients with macroscopic nodal disease should have the diagnosis confirmed preoperatively by image guided fine needle aspiration cytology and undergo staging with whole body PET-CT and MRI brain or CT Brain, Chest Abdomen and Pelvis.

  • Clinical_question:What is the appropriate treatment for macroscopic (i.e. detectable clinically or by ultrasound) nodal metastasis?#Practice_point_1
  • Patients with macroscopic nodal disease should have the diagnosis confirmed preoperatively by image guided fine needle aspiration cytology and undergo staging with whole body PET-CT and MRI brain or CT Brain, Chest Abdomen and Pelvis.
  • Good practice point
Practice pointQuestion mark transparent.png

Patients with a parotid lymph node recurrence should undergo a superficial parotidectomy and upper neck dissection (levels 1B, 2, 3, and upper 5 and possibly 1a).

  • Clinical_question:What is the appropriate treatment for macroscopic (i.e. detectable clinically or by ultrasound) nodal metastasis?#Practice_point_2
  • Patients with a parotid lymph node recurrence should undergo a superficial parotidectomy and upper neck dissection (levels 1B, 2, 3, and upper 5 and possibly 1a).
  • Good practice point
Evidence-based recommendationQuestion mark transparent.png Grade
Complete lymphadenectomy is recommended for patients with palpable or imaging detected lymph node field recurrence.
C
  • Clinical_question:What is the appropriate treatment for macroscopic (i.e. detectable clinically or by ultrasound) nodal metastasis?#Recommendation_1
  • Complete lymphadenectomy is recommended for patients with palpable or imaging detected lymph node field recurrence.
  • Recommendation
Practice pointQuestion mark transparent.png

Complete lymphadenectomy results in improved regional control over lesser procedures.

  • Clinical_question:What is the appropriate treatment for macroscopic (i.e. detectable clinically or by ultrasound) nodal metastasis?#Practice_point_3
  • Complete lymphadenectomy results in improved regional control over lesser procedures.
  • Good practice point
Practice pointQuestion mark transparent.png

All patients with Stage III B/C disease should be presented at a multidisciplinary management meeting.

  • Clinical_question:What is the appropriate treatment for macroscopic (i.e. detectable clinically or by ultrasound) nodal metastasis?#Practice_point_4
  • All patients with Stage III B/C disease should be presented at a multidisciplinary management meeting.
  • Good practice point
Practice pointQuestion mark transparent.png

These high risk patients should be offered the opportunity to enrol in systemic adjuvant or neoadjuvant therapy trials.

  • Clinical_question:What is the appropriate treatment for macroscopic (i.e. detectable clinically or by ultrasound) nodal metastasis?#Practice_point_5
  • These high risk patients should be offered the opportunity to enrol in systemic adjuvant or neoadjuvant therapy trials.
  • Good practice point

Back to top

This guideline includes evidence-based recommendations (EBR), consensus-based recommendations (CBR) and practice points (PP) as defined in the table below. Recommendations and practice points were developed by working party members and sub-committee members.

Each EBR was assigned a grade by the expert working group, taking into account the volume, consistency, generalisability, applicability and clinical impact of the body of evidence according to NHMRC Level and Grades for Recommendations for Guidelines Developers.[1]

NHMRC approved recommendation types and definitions

Type of recommendation
Definition
Evidence-based recommendation
A recommendation formulated after a systematic review of the evidence, indicating supporting references
Consensus-based recommendation
A recommendation formulated in the absence of quality evidence, after a systematic review of the evidence was conducted and failed to identify admissible evidence on the clinical question
Practice point
A recommendation on a subject that is outside the scope of the search strategy for the systematic review, based on expert opinion and formulated by a consensus process

Source: National Health and Medical Research Council. Procedures and requirements for meeting the NHMRC standard for clinical practice guidelines. Melbourne: National Health and Medical Research Council, 2011

Back to top

References

  1. National Health and Medical Research Council. NHMRC levels of evidence and grades for recommendations for guideline developers. Canberra: National Health and Medical Research Council; 2009 Available from: https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_evidence_120423.pdf.