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Cutaneous melanoma

What's new

Updated 2023 ASCO guidelines for the management of cutaneous melanoma.

Background

Overview

Definition
Melanoma is a malignant tumor that arises from pigment-containing cells known as melanocytes, which occurs principally in the skin, but also more rarely in the mouth, intestines, or eyes.
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Pathophysiology
Melanoma is caused by genetic mutations in melanocytes in response to UV-induced DNA damage.
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Epidemiology
The incidence of melanoma in the US is estimated at 21.6 cases per 100,000 persons-year.
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Disease course
The complex interaction between exogenous and endogenous triggers, tumor-intrinsic, and immune-related factors increase the proliferation of melanocytes that is accompanied by genetic mutations leading to malignant transformation of melanocytes to melanoma, which may further metastasize to lymph nodes, skin, lungs, and CNS.
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Prognosis and risk of recurrence
The 5-year and 10-year relative survival for melanoma in the US is around 91.3% and 89.1%, respectively. The relative risk of recurrence for patients < 45 years and ≥ 45 years is 11.89 and 8.36, respectively.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of cutaneous melanoma are prepared by our editorial team based on guidelines from the American Society of Clinical Oncology (ASCO 2023), the U.S. Preventive Services Task Force (USPSTF 2023), the American Society of Plastic Surgeons (ASPS 2021), the British Gynaecological Cancer Society (BGCS 2020), the European Society of Medical Oncology (ESMO ...
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Screening and diagnosis

Indications for screening: as per USPSTF 2023 guidelines, insufficient evidence to assess the balance of benefits and harms of visual skin examination by a clinician to screen for skin cancer in adolescents and adults.
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Diagnostic investigations

Physical examination
As per ESMO 2019 guidelines:
Obtain dermatoscopy by an experienced physician to enhance the diagnostic accuracy.
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Perform physical examination with special attention to other suspicious pigmented lesions, tumor satellites, in-transit metastases, regional lymph nodes, and distant metastases.
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  • Baseline imaging

  • Baseline laboratory tests

Diagnostic procedures

Skin biopsy: as per AAD 2019 guidelines, perform narrow excisional/complete biopsy with 1-3 mm margins encompassing the entire breadth of lesion and of sufficient depth to prevent transection at the base as the preferred biopsy technique. Perform excisional biopsy by any of the following methods:
fusiform/elliptical excision
punch excision around the clinical lesion
deep shave/saucerization removal to depth below the anticipated plane of the lesion.
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  • Sentinel lymph node biopsy

  • Molecular testing

Medical management

Management of melanoma in situ, wide-local excision: as per AAD 2019 guidelines, perform surgical excision with histologically negative margins as first-line treatment in patients with melanoma in situ.
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  • Management of melanoma in situ (primary radiotherapy)

  • Management of melanoma in situ (topical therapy)

  • Management of locoregional disease (neoadjuvant therapy)

  • Management of locoregional disease (wide-local excision)

  • Management of locoregional disease (lymph node dissection)

  • Management of locoregional disease (adjuvant systemic therapy)

  • Management of locoregional disease (adjuvant radiotherapy)

  • Management of advanced/metastatic disease (neoadjuvant therapy)

  • Management of advanced/metastatic disease (systemic therapy)

  • Management of advanced/metastatic disease (resection of metastases)

  • Concurrent use of exogenous hormones

Specific circumstances

Pregnant patients: as per AAD 2019 guidelines, ensure a tailored, multidisciplinary approach of care for pregnant patients with CM, involving obstetrician and CM specialist relevant to the patient's stage of disease. Recognize that the diagnosis of CM during pregnancy does not alter prognosis or outcome for the patient, however take the safety of the fetus into consideration for work-up and treatment.
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  • Patients with mucosal melanoma

  • Patients with vulvar melanoma

Patient education

General counseling
As per AAD 2019 guidelines:
Discuss carefully the associated risks, benefits and uncertainties of non-surgical treatment with the patient and family.
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Educate patients on self-examination of the skin and lymph node for the detection of recurrent disease or new primary CM.
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  • Genetic counseling

Follow-up and surveillance

Assessment for cutaneous toxicity: as per AAD 2019 guidelines, ensure collaboration between dermatologists and oncologists for the management of cutaneous toxicity during BRAF/MEK kinase or immune checkpoint inhibitor therapy because appropriate recognition and control of skin side effects may improve the QoL of patients with CM and avoid unnecessary interruption of medication.
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  • Skin reconstruction after tumor resection (timing)

  • Skin reconstruction after tumor resection (perioperative antibiotics)

  • Skin reconstruction after tumor resection (perioperative antithrombotics)

  • Skin reconstruction after tumor resection (perioperative analgesics)

  • Skin reconstruction after tumor resection (follow-up)

  • Follow-up