Primary Cutaneous Melanoma Clinical Practice Guidelines (2019)

American Academy of Dermatology

Reviewed and summarized by Medscape editors

January 30, 2019

Guidelines on the evaluation and management of primary cutaneous melanoma were released in November 2018 by the American Academy of Dermatology.[1]

Evidence strongly indicates that Breslow thickness, ulceration, and dermal mitotic rate are important predictors of patient outcome in primary cutaneous melanoma.

The recommended first-line treatment for any-thickness primary cutaneous melanoma, as well as for melanoma in situ, is surgical excision with histologically negative margins; tumor thickness should dictate the margins.

Surgical margins for invasive cutaneous melanoma, as measured clinically around the primary tumor, should be a minimum of 1 cm and a maximum of 2 cm, although narrower margins can be employed to accommodate function and/or anatomic location. It is recommended that the excision be as deep as, but not inclusive of, the fascia.

It is not recommended that asymptomatic patients with newly diagnosed stage 0-II primary cutaneous melanoma undergo baseline radiologic imaging and laboratory studies.

For cutaneous melanoma at baseline, radiologic imaging and laboratory studies should be conducted only to assess the specific signs or symptoms of synchronous metastasis (regional nodal or distant).

At baseline or when physical examination of lymph nodes is equivocal and requires surveillance, the employment of lymph node ultrasonography is encouraged. Surveillance with such imaging is also encouraged in patients who meet criteria for sentinel lymph node biopsy (SLNB) but do not undergo the procedure, in patients in whom SLNB is not possible or is technically unsuccessful (eg, because lymphoscintigraphic dye migration has failed and a draining sentinel lymph node cannot be identified), and in those in whom, despite a positive SLNB, complete lymph node dissection is not performed.

Regular clinical follow-up represents the most important strategy for detecting cutaneous melanoma recurrence. The need for further radiologic or laboratory studies to detect local, regional, or distant metastatic disease should be determined via history (review of systems) and physical examination.

Patients should be taught self-examination of the skin and lymph nodes in order to detect recurrent disease or new primary cutaneous melanoma.

For the first 3 months of BRAF inhibitor monotherapy, patients with numerous squamoproliferative neoplasms should undergo dermatologic evaluation every 2-4 weeks, although less skin toxicity is associated with the standard treatment, combination BRAF/MEK inhibition.

Patients being treated with immune checkpoint inhibitors should undergo dermatologic evaluation within the first month of therapy, with such assessment being continued as needed to manage dermatologic side effects.

For more information, please go to Melanoma.

For more Clinical Practice Guidelines, please go to Guidelines.

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