Summary of recommendations

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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 validated models integrate genetic and clinical risk factors into an overall measurement of high risk from new primary melanoma?

Evidence-based recommendationQuestion mark transparent.png Grade
Assess all patients for future risk of melanoma, using validated risk factors and a model that integrates personal risk factors into an overall index of risk.
B
  • Clinical question:What validated models integrate genetic and clinical risk factors into an overall high risk measurement for new primary melanoma?#Recommendation_1
  • Assess all patients for future risk of melanoma, using validated risk factors and a model that integrates personal risk factors into an overall index of risk.
  • Recommendation

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What interventions have been shown to reduce the risk of death from melanoma in those assessed to be at high risk of new primary melanoma?

Evidence-based recommendationQuestion mark transparent.png Grade
Individuals at very high risk of melanoma and their partner or carer should be educated to recognise and document lesions suspicious of melanoma. These individuals should be checked regularly by a clinician with six-monthly full skin examination supported by total body photography and dermoscopy.
C
  • Clinical question:What interventions reduce risk of death from melanoma in high risk people?#Recommendation_1
  • Individuals at very high risk of melanoma and their partner or carer should be educated to recognise and document lesions suspicious of melanoma. These individuals should be checked regularly by a clinician with six-monthly full skin examination supported by total body photography and dermoscopy.
  • Recommendation

What clinical information should the clinician give the pathologist to aid diagnosis of melanoma?

Practice pointQuestion mark transparent.png

It is advisable that as much relevant clinical information (Table 1) as possible be provided to pathologists to aid in the diagnosis of melanoma.

  • Clinical question:Clinical information for pathologist#Practice_point_1
  • It is advisable that as much relevant clinical information (Table 1) as possible be provided to pathologists to aid in the diagnosis of melanoma.
  • Good practice point

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

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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
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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

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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
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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
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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

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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
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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
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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
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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
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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
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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

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Should all patients with a positive sentinel lymph node biopsy have a complete node dissection?

Evidence-based recommendationQuestion mark transparent.png Grade
CLND is no longer the preferred treatment for patients with a positive SLNB. CLND or active surveillance are equivalent in terms of 3 year melanoma specific survival but CLND is more morbid.
B
  • Clinical question:Should all patients with a positive sentinel lymph node biopsy have a complete node dissection?#Recommendation_1
  • CLND is no longer the preferred treatment for patients with a positive SLNB. CLND or active surveillance are equivalent in terms of 3 year melanoma specific survival but CLND is more morbid.
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
CLND offers high levels of immediate regional control for patients with positive SLNB however good regional control can be achieved with delayed CLND.
C
  • Clinical question:Should all patients with a positive sentinel lymph node biopsy have a complete node dissection?#Recommendation_2
  • CLND offers high levels of immediate regional control for patients with positive SLNB however good regional control can be achieved with delayed CLND.
  • Recommendation
Practice pointQuestion mark transparent.png

To date there is no subgroup of patients for whom immediate CLND is likely to provide a clear benefit, however patients with a high risk of further non-SLN involvement and particularly those who are less likely to suffer significant morbidity from CLND may choose to have the procedure to reduce the risk of lymph node field relapse. A risk calculator for defining the likelihood of non-SLN involvement such as the N-SNORE (Murali et al. 2010) can be of assistance to more accurately estimate the probability of residual non-SN positive nodes.

  • Clinical question:Should all patients with a positive sentinel lymph node biopsy have a complete node dissection?#Practice_point_1
  • To date there is no subgroup of patients for whom immediate CLND is likely to provide a clear benefit, however patients with a high risk of further non-SLN involvement and particularly those who are less likely to suffer significant morbidity from CLND may choose to have the procedure to reduce the risk of lymph node field relapse. A risk calculator for defining the likelihood of non-SLN involvement such as the N-SNORE (Murali et al. 2010) can be of assistance to more accurately estimate the probability of residual non-SN positive nodes.
  • Good practice point
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Close clinical and ultrasound surveillance using a protocol equivalent to that followed in MSLT-II and DeCOG-SLT of 3-4 monthly clinical examination and ultrasound of the regional lymph node field for 2 years and then the same at least 6 monthly for a total of 5 years, then annual clinical review is required if a patient with a positive SLNB chooses active surveillance.

  • Clinical question:Should all patients with a positive sentinel lymph node biopsy have a complete node dissection?#Practice_point_2
  • Close clinical and ultrasound surveillance using a protocol equivalent to that followed in MSLT-II and DeCOG-SLT of 3-4 monthly clinical examination and ultrasound of the regional lymph node field for 2 years and then the same at least 6 monthly for a total of 5 years, then annual clinical review is required if a patient with a positive SLNB chooses active surveillance.
  • Good practice point

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
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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
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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
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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

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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
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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
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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

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What is the role of dermoscopy in melanoma diagnosis?

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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

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

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Only flat or slightly raised lesions should undergo dermoscopy monitoring. Suspicious nodular lesions should not be monitored but should be excised.

  • 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. Suspicious nodular lesions should not be monitored but should be excised.
  • Good practice point
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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
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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

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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

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What is the role of skin surface imaging in the early diagnosis of patients at high risk of developing melanoma?

Evidence-based recommendationQuestion mark transparent.png Grade
Consider the use of total body photography in managing patients at increased risk for melanoma, particularly those with high naevus counts and dysplastic naevi.
C
  • Clinical question:Melanoma total body photography#Recommendation_1
  • Consider the use of total body photography in managing patients at increased risk for melanoma, particularly those with high naevus counts and dysplastic naevi.
  • Recommendation
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TBP allows monitoring of most of the skin surface, including most existing skin lesions. TBP should be the primary imaging intervention for early melanoma detection in patients at elevated risk who have high naevus counts or multiple dysplastic naevi.

  • Clinical question:Melanoma total body photography#Practice_point_1
  • TBP allows monitoring of most of the skin surface, including most existing skin lesions. TBP should be the primary imaging intervention for early melanoma detection in patients at elevated risk who have high naevus counts or multiple dysplastic naevi.
  • Good practice point

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What investigations should be performed following a diagnosis of primary cutaneous melanoma for asymptomatic stage I and stage II patients?

Evidence-based recommendationQuestion mark transparent.png Grade
Chest x-ray imaging for initial staging should not be performed
C
  • Clinical question:What investigations should be performed following a diagnosis of primary cutaneous melanoma for asymptomatic Stage I and II patients?#Recommendation_1
  • Chest x-ray imaging for initial staging should not be performed
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
CT head, chest, abdomen and pelvis imaging are not recommended for initial staging in asymptomatic patients with stage IIB or IIC melanoma. In addition, there is no evidence to support CT imaging in Stage I and IIA melanoma.
C
  • Clinical question:What investigations should be performed following a diagnosis of primary cutaneous melanoma for asymptomatic Stage I and II patients?#Recommendation_2
  • CT head, chest, abdomen and pelvis imaging are not recommended for initial staging in asymptomatic patients with stage IIB or IIC melanoma. In addition, there is no evidence to support CT imaging in Stage I and IIA melanoma.
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
CT imaging for initial staging is not recommended for patients with stage I-II melanoma
C
  • Clinical question:What investigations should be performed following a diagnosis of primary cutaneous melanoma for asymptomatic Stage I and II patients?#Recommendation_3
  • CT imaging for initial staging is not recommended for patients with stage I-II melanoma
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
PET/CT imaging for initial staging is not recommended for patients with a thin, or intermediate Breslow thickness primary melanoma (Stage I-IIB).
C
  • Clinical question:What investigations should be performed following a diagnosis of primary cutaneous melanoma for asymptomatic Stage I and II patients?#Recommendation_4
  • PET/CT imaging for initial staging is not recommended for patients with a thin, or intermediate Breslow thickness primary melanoma (Stage I-IIB).
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
MRI imaging of the head, spine or extremities is not recommended for initial staging in patients with stage I or stage II melanoma.
D
  • Clinical question:What investigations should be performed following a diagnosis of primary cutaneous melanoma for asymptomatic Stage I and II patients?#Recommendation_5
  • MRI imaging of the head, spine or extremities is not recommended for initial staging in patients with stage I or stage II melanoma.
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
S100B, MIA and LDH or standard blood tests are not recommended at initial staging for diagnosis of metastatic melanoma.
C
  • Clinical question:What investigations should be performed following a diagnosis of primary cutaneous melanoma for asymptomatic Stage I and II patients?#Recommendation_6
  • S100B, MIA and LDH or standard blood tests are not recommended at initial staging for diagnosis of metastatic melanoma.
  • Recommendation
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Low sensitivity, specificity, and accuracy for general laboratory profiles (S100B, MIA, LDH blood tests) make them ineffective in the detection of subclinical recurrence and their roles are yet to be defined.

  • Clinical question:What investigations should be performed following a diagnosis of primary cutaneous melanoma for asymptomatic Stage I and II patients?#Practice_point_1
  • Low sensitivity, specificity, and accuracy for general laboratory profiles (S100B, MIA, LDH blood tests) make them ineffective in the detection of subclinical recurrence and their roles are yet to be defined.
  • Good practice point

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What investigations should be performed when in transit and/or regional node disease (Stage III melanoma) is diagnosed?

Evidence-based recommendationQuestion mark transparent.png Grade
FNB, with or without ultrasound guidance can be used to confirm the diagnosis of lymph node or intransit metastatic melanoma
B
  • Clinical question:What investigations should be performed when in transit and/or regional node disease (Stage III melanoma) is diagnosed?#Recommendation_1
  • FNB, with or without ultrasound guidance can be used to confirm the diagnosis of lymph node or intransit metastatic melanoma
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
Core biopsy can be used to confirm the diagnosis of lymph node or intransit metastatic melanoma
C
  • Clinical question:What investigations should be performed when in transit and/or regional node disease (Stage III melanoma) is diagnosed?#Recommendation_2
  • Core biopsy can be used to confirm the diagnosis of lymph node or intransit metastatic melanoma
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
Consider NOT performing PET/CT or CT in newly diagnosed sentinel node positive patients
C
  • Clinical question:What investigations should be performed when in transit and/or regional node disease (Stage III melanoma) is diagnosed?#Recommendation_3
  • Consider NOT performing PET/CT or CT in newly diagnosed sentinel node positive patients
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
Perform a PET/CT scan for the initial staging of stage III melanoma patients with palpable nodal disease.
B
  • Clinical question:What investigations should be performed when in transit and/or regional node disease (Stage III melanoma) is diagnosed?#Recommendation_4
  • Perform a PET/CT scan for the initial staging of stage III melanoma patients with palpable nodal disease.
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
A brain scan (high resolution CT or MRI) should be added to a PET/CT scan to assess for the presence of brain metastases.
B
  • Clinical question:What investigations should be performed when in transit and/or regional node disease (Stage III melanoma) is diagnosed?#Recommendation_5
  • A brain scan (high resolution CT or MRI) should be added to a PET/CT scan to assess for the presence of brain metastases.
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
Consider using an MRI scan rather than a CT scan to assess for the presence of brain metastases.
B
  • Clinical question:What investigations should be performed when in transit and/or regional node disease (Stage III melanoma) is diagnosed?#Recommendation_6
  • Consider using an MRI scan rather than a CT scan to assess for the presence of brain metastases.
  • Recommendation
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Ultrasound may be used for identification of the extent of intransit and nodal disease, and also used to diagnose liver metastases.

  • Clinical question:What investigations should be performed when in transit and/or regional node disease (Stage III melanoma) is diagnosed?#Practice_point_1
  • Ultrasound may be used for identification of the extent of intransit and nodal disease, and also used to diagnose liver metastases.
  • Good practice point
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Other countries consider performing S100B in stage III patients with palpable nodal disease, but this is not PBS available in Australia.

  • Clinical question:What investigations should be performed when in transit and/or regional node disease (Stage III melanoma) is diagnosed?#Practice_point_2
  • Other countries consider performing S100B in stage III patients with palpable nodal disease, but this is not PBS available in Australia.
  • Good practice point

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What investigations should be performed when Stage IV melanoma is diagnosed?

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Serum LDH level should be measured at the time of diagnosis of stage IV melanoma.

  • Clinical question:What investigations should be performed when Stage IV melanoma is diagnosed?#Practice_point_1
  • Serum LDH level should be measured at the time of diagnosis of stage IV melanoma.
  • Good practice point
Evidence-based recommendationQuestion mark transparent.png Grade
Whole body PET scanning or PET/CT is required in patients diagnosed with stage IV melanoma if the result will change management.
A
  • Clinical question:What investigations should be performed when Stage IV melanoma is diagnosed?#Recommendation_1
  • Whole body PET scanning or PET/CT is required in patients diagnosed with stage IV melanoma if the result will change management.
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
Brain imaging with contrast enhanced CT or MRI is appropriate in asymptomatic patients diagnosed with stage IV melanoma.
C
  • Clinical question:What investigations should be performed when Stage IV melanoma is diagnosed?#Recommendation_2
  • Brain imaging with contrast enhanced CT or MRI is appropriate in asymptomatic patients diagnosed with stage IV melanoma.
  • Recommendation
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Documentation of the presence/absence of activating V600 BRAF mutations in tumour tissue is required before commencing systemic therapy for stage IV melanoma.

  • Clinical question:What investigations should be performed when Stage IV melanoma is diagnosed?#Practice_point_2
  • Documentation of the presence/absence of activating V600 BRAF mutations in tumour tissue is required before commencing systemic therapy for stage IV melanoma.
  • Good practice point

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How should patients at each stage of melanoma be followed after initial definitive treatment?

Evidence-based recommendationQuestion mark transparent.png Grade
Self-examination is recommended following definitive local treatment for melanoma patients of any stage.
C
  • Clinical question:How should patients at each stage of melanoma be followed after initial definitive treatment?#Recommendation_1
  • Self-examination is recommended following definitive local treatment for melanoma patients of any stage.
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
History and physical examination by a patient’s preferred medical practitioner should be undertaken for the detection of early, treatable recurrence following definitive treatment of stage I to stage III melanoma.
C
  • Clinical question:How should patients at each stage of melanoma be followed after initial definitive treatment?#Recommendation_2
  • History and physical examination by a patient’s preferred medical practitioner should be undertaken for the detection of early, treatable recurrence following definitive treatment of stage I to stage III melanoma.
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
Routine blood or radiological investigations are not recommended for the follow-up of asymptomatic stage I to stage IIB melanoma patients after definitive local treatment.
C
  • Clinical question:How should patients at each stage of melanoma be followed after initial definitive treatment?#Recommendation_3
  • Routine blood or radiological investigations are not recommended for the follow-up of asymptomatic stage I to stage IIB melanoma patients after definitive local treatment.
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
Routine radiological investigations every 3-12 months may be considered for the first three years of follow up after definitive local treatment of stage IIC and III melanoma where detection of recurrence would allow early commencement of systemic therapy. However, there are currently no high-quality data that early detection and treatment of recurrence improves survival.
C
  • Clinical question:How should patients at each stage of melanoma be followed after initial definitive treatment?#Recommendation_4
  • Routine radiological investigations every 3-12 months may be considered for the first three years of follow up after definitive local treatment of stage IIC and III melanoma where detection of recurrence would allow early commencement of systemic therapy. However, there are currently no high-quality data that early detection and treatment of recurrence improves survival.
  • Recommendation
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Skin self-examination by patients is essential and they should be taught the process. Routine follow-up by the patient’s preferred health professional may be appropriate to emphasise sun smart behaviour and perform skin checks, especially in ‘hard to see’ areas.

  • Clinical question:How should patients at each stage of melanoma be followed after initial definitive treatment?#Practice_point_1
  • Skin self-examination by patients is essential and they should be taught the process. Routine follow-up by the patient’s preferred health professional may be appropriate to emphasise sun smart behaviour and perform skin checks, especially in ‘hard to see’ areas.
  • Good practice point
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Routine radiological imaging PET/CT or CT may be considered for patients with stage IIC or III melanoma for the early detection of recurrence, particularly in the context of a clinical trial. However, patients should be counselled regarding the potential risks of false positives, anxiety, and the risks of radiation including thyroid cancer and cataracts.

  • Clinical question:How should patients at each stage of melanoma be followed after initial definitive treatment?#Practice_point_2
  • Routine radiological imaging PET/CT or CT may be considered for patients with stage IIC or III melanoma for the early detection of recurrence, particularly in the context of a clinical trial. However, patients should be counselled regarding the potential risks of false positives, anxiety, and the risks of radiation including thyroid cancer and cataracts.
  • Good practice point

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What is the ideal setting, duration and frequency of follow-up for melanoma patients?

Evidence-based recommendationQuestion mark transparent.png Grade
Routine follow-up by the patient’s preferred doctor may be appropriate to emphasise sun smart behaviour and perform skin checks.
C
  • Clinical question:What is the ideal setting, duration and frequency of follow-up for melanoma patients?#Recommendation_1
  • Routine follow-up by the patient’s preferred doctor may be appropriate to emphasise sun smart behaviour and perform skin checks.
  • Recommendation
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It may be beneficial for medical professionals conducting follow up examinations for melanoma patients to be familiar with skin examination and dermatoscopy.

  • Clinical question:What is the ideal setting, duration and frequency of follow-up for melanoma patients?#Practice_point_1
  • It may be beneficial for medical professionals conducting follow up examinations for melanoma patients to be familiar with skin examination and dermatoscopy.
  • Good practice point
Evidence-based recommendationQuestion mark transparent.png Grade
Risk adjusted follow up looking for recurrence based on stage at presentation should be considered over a time period of 5-10 years for stages I-II melanoma. For surgically resected stage III melanoma, the most intensive follow up should be for the first 3 years.
C
  • Clinical question:What is the ideal setting, duration and frequency of follow-up for melanoma patients?#Recommendation_2
  • Risk adjusted follow up looking for recurrence based on stage at presentation should be considered over a time period of 5-10 years for stages I-II melanoma. For surgically resected stage III melanoma, the most intensive follow up should be for the first 3 years.
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
Melanoma survivors should be made aware of their risk of developing further primary melanomas, and of the consequent need for careful lifelong skin surveillance.
C
  • Clinical question:What is the ideal setting, duration and frequency of follow-up for melanoma patients?#Recommendation_3
  • Melanoma survivors should be made aware of their risk of developing further primary melanomas, and of the consequent need for careful lifelong skin surveillance.
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
Follow-up intervals:
  • Stage I: follow-up annually for 10 years
  • Stage IIA: every 6 months for 2 years, then annually for 8 years
  • Stage IIB and IIC: every 3 to 4 months for 2 years, every 6 months during year 3, then annually for 5 years.
  • Stage IIIA-C: every 3 months for 2 years, every 6 months during year 3, then annually for 5 years.
C
  • Clinical question:What is the ideal setting, duration and frequency of follow-up for melanoma patients?#Recommendation_4
  • Follow-up intervals:
  • Stage I: follow-up annually for 10 years
  • Stage IIA: every 6 months for 2 years, then annually for 8 years
  • Stage IIB and IIC: every 3 to 4 months for 2 years, every 6 months during year 3, then annually for 5 years.
  • Stage IIIA-C: every 3 months for 2 years, every 6 months during year 3, then annually for 5 years.
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
While it is important that clinicians weigh up the advantages and disadvantages of undertaking routine follow-up, individual patient’s needs should be considered before appropriate follow-up is offered.
C
  • Clinical question:What is the ideal setting, duration and frequency of follow-up for melanoma patients?#Recommendation_5
  • While it is important that clinicians weigh up the advantages and disadvantages of undertaking routine follow-up, individual patient’s needs should be considered before appropriate follow-up is offered.
  • Recommendation

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When is radiotherapy indicated for patients with distant metastasis?

Evidence-based recommendationQuestion mark transparent.png Grade
Stereotactic radiosurgery (SRS) should be considered for patients with single or a small number of brain metastases to maximise local control.
C
  • Clinical question:When is radiotherapy indicated for melanoma patients with distant metastasis?#Recommendation_1
  • Stereotactic radiosurgery (SRS) should be considered for patients with single or a small number of brain metastases to maximise local control.
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
For patients with multiple brain metastases, whole brain radiation therapy may provide some palliative benefits.
C
  • Clinical question:When is radiotherapy indicated for melanoma patients with distant metastasis?#Recommendation_2
  • For patients with multiple brain metastases, whole brain radiation therapy may provide some palliative benefits.
  • Recommendation
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All melanoma patients with distant metastases should be reviewed at a multidisciplinary team meeting to ensure optimal drug, surgery and RT treatment combination.

  • Clinical question:When is radiotherapy indicated for melanoma patients with distant metastasis?#Practice_point_1
  • All melanoma patients with distant metastases should be reviewed at a multidisciplinary team meeting to ensure optimal drug, surgery and RT treatment combination.
  • Good practice point
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Patients with single or a small number of brain metastases should be given the opportunity to discuss adjuvant radiotherapy to the surgical cavity and/or the whole brain.

  • Clinical question:When is radiotherapy indicated for melanoma patients with distant metastasis?#Practice_point_2
  • Patients with single or a small number of brain metastases should be given the opportunity to discuss adjuvant radiotherapy to the surgical cavity and/or the whole brain.
  • Good practice point
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Patients with painful bone metastasis should be considered for short course of RT for pain relief.

  • Clinical question:When is radiotherapy indicated for melanoma patients with distant metastasis?#Practice_point_3
  • Patients with painful bone metastasis should be considered for short course of RT for pain relief.
  • Good practice point
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RT should be considered in patients with problematic skin, soft tissue or nodal metastasis that have not responded to systemic therapy.

  • Clinical question:When is radiotherapy indicated for melanoma patients with distant metastasis?#Practice_point_4
  • RT should be considered in patients with problematic skin, soft tissue or nodal metastasis that have not responded to systemic therapy.
  • Good practice point

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

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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
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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
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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
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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
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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

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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

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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.