Management of Locoregional Melanoma Clinical Practice Guidelines (ESMO, 2020)

European Society for Medical Oncology

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.

September 02, 2020

The guideline update on management of locoregional melanoma was released on August 4, 2020 by the European Society for Medical Oncology.[1]

Sentinel Lymph Node Biopsy

Sentinel lymph node biopsy (SLNB) is recommended for staging in melanomas of stage pT2a or higher (>1.0 mm Breslow thickness).

SLNB should be discussed with patients with a melanoma of stage pT1b (ie, with tumor thickness >0.8–1.0 mm, or <0.8 mm with ulceration).

SLNB is not routinely recommended for patients with a melanoma of stage pT1a (eg, with tumor thickness <0.8 mm and no ulceration).

SLNB can be discussed in pT1a for special cases (eg, ≥3 mitoses/mm2, positive deep margin, or when Breslow thickness cannot be reliably determined [pTx]).

Wide Local Excision

In the context of resectable clinical stage III disease, primary melanomas should be removed with clear margins to ensure local control. Wide local excision (WLE), ideally with a clinical 1 cm margin, is advised, with primary closure to avoid reconstruction whenever possible.

In the context of clinical stage IV disease, in the absence of symptoms or need for diagnostic tissue, there is no need to resect the primary tumor. If there is an indication to resect the primary lesion, resection should be with clear margins, but without additional safety margins.

Radical Lymph Node Dissection

Radical lymph node dissection is recommended for cases of clinically detected lymph node metastases in resectable stage III disease after pathological assessment (cytology or histology of lesion preoperatively) and adequate staging.

When lymph node surgery is indicated, radical node dissection is recommended over “node picking” (ie, removal of only lymph nodes with clinically apparent disease).

Groin: If imaging does not show any iliac involvement, an inguinal dissection is sufficient. If iliac disease is also present, a combined ilio-inguinal dissection should be performed.

Axilla: Complete clearance of the axilla, including level I–III, should be performed.

Neck: Modified radical neck dissection is recommended. Parotidectomy should be performed only if there is evidence of involvement of the parotid.

Treatment of Satellite or In-Transit Metastases

For resectable in-transit metastases that can comprise few, small, and non–rapidly-recurrent lesions, resection with clear margins—but without additional safety margins—is recommended. Extensive and multiple repeated resections and reconstructions should be avoided.

Unresectable satellite/in-transit metastases, or inoperable primary tumors of the limbs without additional metastases, may be treated with locoregional treatments (eg, isolated limb perfusion or infusion, talimogene laherparepvec [T-VEC], electrochemotherapy, 10% rose Bengal solution [PV-10]).

Adjuvant Radiotherapy After Node Dissection

For patients with advanced stage III disease that has been treated with lymphadenectomy, the primary recommendation is adjuvant systemic therapy and observation, reserving additional surgery and radiotherapy (RT) for any recurrent disease. However, adjuvant RT could be useful for high-risk patients where regional control is a major issue and/or where systemic therapy is not possible.

Neoadjuvant Therapy

For easily resectable stage III disease with acceptable surgical morbidity, neoadjuvant strategies should be considered only in the context of a clinical trial. Outside of a clinical trial, neoadjuvant strategies should be considered for technically resectable but bulky nodal and/or in-transit disease when surgery will be associated with significant morbidity, likely to result in positive resection margin status, or necessitate postoperative RT.

Continuing treatment after surgery should be considered based on the pathological response evaluation of the surgical specimen.

In principle, the standard surgical approach should be used after neoadjuvant therapy until studies show that it is safe to omit or modify surgery. Tailoring of the extent of surgery can be considered if there is a major radiological or pathological response for disease that extends outside of the nodal basin.

Adjuvant Therapy for BRAF-Mutated Melanoma

Current evidence suggests that patients with BRAF-mutated melanoma can derive a recurrence-free survival benefit from either adjuvant BRAF/MEK inhibition or adjuvant PD-1 blockade. In the absence of a direct efficacy comparison, individual treatment decisions should be made with the patient, factoring in the toxicity profiles for the different adjuvant treatment approaches.

Adjuvant Therapy in Stage IIIA Melanoma

An absolute survival benefit of 5% at 5 years would be considered strong evidence to recommend adjuvant therapy in stage III melanoma. However, surrogate markers of overall survival benefit are currently acceptable.

There is currently insufficient evidence to support the routine use of adjuvant therapy in stage IIIA melanoma.

There may be some subsets of stage IIIA patients with a higher risk of relapse (eg, tumor burden in sentinel node >1 mm). In these patients, a balanced discussion of risk reduction and long-term side effects of adjuvant therapy can be considered.

Management of Toxicity in the Adjuvant Setting

The management of toxicity from adjuvant therapy should be done according to the established management algorithms for metastatic disease.

When adjuvant immunotherapy is withheld because of severe toxicity, the recommendation is neither to restart treatment nor to start an alternative adjuvant therapy.

Adjuvant Therapy for In-Transit Metastases and Resected Stage IV Disease

Adjuvant dabrafenib plus trametinib can be considered in patients with completely resected BRAF V600–mutated stage IV melanoma if there is a contraindication to immunotherapy.

Adjuvant therapy may be considered for patients with completely resected in-transit melanoma or microsatellites, including patients without evidence of nodal metastasis.

In cases of resectable locoregional relapse in patients receiving adjuvant therapy, whether to resume adjuvant therapy after complete resection remains controversial in the absence of prospective clinical data.

For more information, see Malignant Melanoma. For more Clinical Practice Guidelines, please go to Guidelines.


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