Melanoma Clinical Practice Guidelines (2020)

European Dermatology Forum, European Association of Dermato-Oncology, and European Organization for Research and Treatment of Cancer

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

January 31, 2020

Consensus-based interdisciplinary guidelines on the diagnosis and treatment of melanoma were released in January 2020 by the European Dermatology Forum, the European Association of Dermato-Oncology, and the European Organization for Research and Treatment of Cancer.[1,2]

Diagnostic Guidelines

The 8th edition of the American Joint Committee on Cancer should be used for classification into prognostic stages.

When melanoma is suspected based on clinical findings, it should be confirmed using histopathology studies.

Dermatoscopy should be used for assessing all nonpigmented and pigmented skin lesions. Training in dermatoscopy is considered mandatory.

Use whole-body photography with sequential examinations when assessing high-risk patients for early melanoma detection.

Use sequential digital dermatoscopy to help improve early melanoma detection; this technique should be used in high-risk patients in whom the total nevus count is high.

The use of confocal laser microscopy can be considered for the further evaluation of clinically or dermatoscopically equivocal skin lesions.

Ultrasonography should be performed on locoregional lymph nodes as part of the initial workup for all primary melanomas staged pT1b or higher.

Follow-Up on Diagnosis

Goals for follow up after a melanoma diagnosis are as follows:

  • Identification of recurrent disease (ie, local, distant) at the earliest possible stage

  • Psychosocial support

  • Education on prevention, including advice for both patients and their first-degree relatives

  • Education for patients and their families regarding skin self-examination in order to improve early melanoma detection

  • Providing monitoring of adjuvant therapy in the appropriate clinical situation

  • Improving the chances for early detection of subsequent secondary melanoma and nonmelanoma skin cancers

  • Recognize and treat adverse cutaneous effects that may result from adjuvant or palliative treatment

To aid in detection of recurrence, perform stage-specific follow up for at least 5 years.

To aid in the detection of new primary or other skin cancers, perform follow up for least 10 years.

Treatment Guidelines

If melanoma is suspected, completely excise the entire lesion with narrow (1- to 3-mm) margins in order to perform a histological diagnosis. Incisional biopsy can be used for large lesions, such as those on the face (eg, lentigo maligna), for acral lesions, and for those on the genitalia.

If melanoma cannot be excluded, do not use blind destructive treatments (eg, cryotherapy, laser, topical drugs).

In the case of primary melanoma, secondary excision (reexcision) should be performed in order to reduce the risk of local recurrence. Recommended peripheral surgical margins are 1 cm for tumors 0.5 mm to <2 mm thick and 2 cm for tumors >2 mm thick. Excision is not recommended for larger lesions.

In exceptional circumstances for particular anatomic locations in order to preserve function and/or allow for reconstruction (eg, facial, acral, and genital regions), narrower reexcision margins may be considered.

Microscopically controlled surgery can be used to spare tissue and achieve compete resection in particular melanoma subtypes such as lentigo maligna melanoma and in genital and acral melanomas.

Use sentinel lymph node biopsy (SLNB) for accurate stage classification and to aid in treatment decisions in patients with tumors 1 mm or thicker or, if 0.8 mm or thicker and having additional histological risk factors.

In patients in whom SLNB shows micrometastasis, complete lymphadenectomy is no longer recommended. Adjuvant systemic therapy and stage-specific follow-up are indicated.

If clinical findings or imaging findings indicate regional lymph node metastases, complete lymphadenectomy should be performed.

A complete metastasectomy can be considered in cases of oligometastatic disease when complete resection is feasible.

Recommendations for adjuvant therapy in stage III/IV disease are as follows:

  • Stage IIIA-IIID and fully resected stage IV: Adjuvant therapy should be offered, with anti–programmed cell death protein 1 (PD-1) therapy or targeted therapy.

  • Stage IIIA-IIID and fully resected stage IV, regardless of mutational status: Adjuvant therapy can be offered, with anti–PD-1 therapy or targeted therapy.

  • Stage IIIA-IIID with BRAF-V600 E/K mutation: Adjuvant therapy can be offered, with BRAF/MEK inhibitor therapy.

  • Stage IIIA with nodal metastasis of <1 mm in diameter: Risk-to-benefit ratio should be carefully discussed with the patient.

First-line therapy in patients with stage IV disease is immunotherapy with checkpoint inhibitors; options include anti–PD-1 monotherapy and combination anti–PD-1 plus anti–cytotoxic T-lymphocyte antigen 4 (CTLA-4) therapy.

In certain situations, such as in patients with stage IV melanoma and BRAF-V600 E/K mutation, an alternative to immunotherapy is first-line therapy with BRAF/MEK inhibitors.

Chemotherapy should only be considered if resistance to immunotherapy and targeted therapies is present.

In patients with brain metastases, treat with stereotactic radiotherapy. Surgery is an option if stereotactic radiotherapy is not possible.

Do not use whole-brain radiotherapy for melanoma brain metastases.

Regarding systemic therapy for brain metastases, preferred therapy is combined immunotherapy. An alternative in patients with BRAF-V600 E/K mutations is targeted therapy.

For more information go to Malignant Melanoma and Cutaneous Melanoma.

For more Clinical Practice Guidelines, go to Guidelines.

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