Primary Cutaneous Melanoma Treatment
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2019 AAD Guidelines for management of Primary Cutaneous Melanoma (CM) |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Anum Ijaz M.B.B.S., M.D.[2]
2019 AAD Guidelines for Treatment of Primary Cutaneous Melanoma
Recommendations for Surgical Management of Primary CM
| Class A |
| 1. Surgical excision with histologically negative margins is the recommended and first-line treatment for primary CM of any thickness, as well as for melanoma in situ. Surgical margins should be based on tumor thickness. (Level of Evidence:Ⅰ) |
| 2. Surgical margins for invasive CM should be ≥1 cm and ≤ 2 cm measured clinically around the primary tumor, although margins may be narrower to accommodate function and/or anatomic location. Depth of excision is recommended to (but not including) the fascia.(Level of Evidence:Ⅰ) |
| Class B |
| 1. For melanoma in situ, wide excision with 0.5- to 1.0-cm margins is recommended; MIS, LM type, may require >0.5-cm margins to achieve histologically negative margins because of subclinical extension. (Level of Evidence:Ⅱ/Ⅲ) |
| 2. Mohs micrographic surgery* or staged excision with paraffin-embedded permanent sections may be utilized for MIS, LM type, on the face, ears, or scalp for tissue-sparing excision and exhaustive histologic assessment of peripheral margins.(Level of Evidence:Ⅱ/Ⅲ) |
| 3. For MIS, LM type, permanent section analysis of the central MMS debulking specimen is recommended to identify and appropriately stage potential invasive CM. If invasive CM is identified on a MMS section intraoperatively, the tissue should be submitted for formal pathology review.(Level of Evidence:Ⅱ/Ⅲ) |
| Class C |
| 1. Sub-1-cm margins (by either WE or MMS) for primary invasive melanomas at anatomically constrained sites (eg, head and neck, acral sites) are generally not recommended until further studies are available. (Level of Evidence:Ⅲ) |
*-CM, Cutaneous melanoma; MIS, LM, melanoma in situ, lentigo maligna; MMS, Mohs micrographic surgery; WE, wide excision. [1]
Recommendations for Sentinal Lymph Node Biopsy
| Class B |
| 1. SLNB is not recommended for patients with MIS or for most T1a CM (<0.8 mm without ulceration per the eighth edition of the AJCC staging system).(Level of Evidence:Ⅰ/Ⅱ) |
| 2. SLNB should be discussed and offered in appropriate patients with CM >1 mm thickness (≥T2a), including T4 CM (Level of Evidence:Ⅰ/Ⅱ) |
| 3. In patients with T1b CM (<0.8 mm with ulceration or 0.8-1.0 mm with or without ulceration per the eighth edition of the AJCC staging system), SLNB should be discussed and considered, though rates of SLN positivity are still relatively low (Level of Evidence:Ⅰ/Ⅱ) |
| 4. SLNB may be considered for T1a CM if other adverse features are present, including young age, presence of lymphovascular invasion, positive deep biopsy margin (if close to 0.8 mm), high mitotic rate, or a combination of these factors (Level of Evidence:Ⅰ/Ⅱ) |
*-SLNB = sentinel lymph node biopsy. [1]
| Class C |
| 1. Sentinel lymph node biopsy, when indicated, should be performed before wide excision of the primary tumor, and in the same operative setting, whenever possible (Level of Evidence:Ⅲ) |
| 2. For all SLNB-eligible patients, careful discussion of the risks and benefits of the procedure involving surgical oncology input is recommended(Level of Evidence:Ⅲ/Expert Opinion) |
| 3. Interdisciplinary collaboration involving surgical and medical oncologists is recommended for discussion of possible completion lymph node dissection vs regional nodal ultrasound surveillance in the event of a positive SLNB(Level of Evidence:Ⅲ/Expert Opinion) |
*-AJCC = American Joint Committee on Cancer; CM = cutaneous melanoma; MIS = melanoma in situ; SLN = sentinel lymph node; SLNB = sentinel lymph node biopsy. [1]
Recommendations for the use of Imiquimod or Radiation Therapy
| Class B |
| 1. Topical imiquimod 5% cream may be used as second-line treatment for MIS, LM type, when surgery is not possible at the outset (primary setting) or when optimal surgery has been performed (adjuvant setting). Careful discussion of the associated risks, benefits, and uncertainties of nonsurgical treatment should take place with the patient and family. (Level Ⅱ/Ⅲ ) |
| 2. Adjuvant RT after WE may be used for desmoplastic CM with high-risk features (eg, Breslow thickness [4 mm, Clark level V, extensive neurotropism/perineural invasion, head and neck location, and/or narrow deep margin resection).(Level Ⅱ/Ⅲ ) |
| Class C |
| 1. For nonsurgical candidates, RT may be utilized as a second-line therapy for MIS, LM type, though its use is uncommon in the United States. (Level Ⅱ/Ⅲ ) |
| 2. The use of superficial brachytherapy for MIS, LM type, is not recommended. (Level Ⅲ,Expert Opinion) |
| 3.Consultation with a radiation oncologist is recommended to discuss the associated risks and potential benefits of RT.(Level Ⅲ,Expert Opinion ) |
*-CM= Cutaneous melanoma; MIS= melanoma in situ, LM= lentigo maligna; RT= radiation therapy; WE= wide excision. [1]
Reference
Swetter SM, Tsao H, Bichakjian CK, Curiel-Lewandrowski C, Elder DE, Gershenwald JE, Guild V, Grant-Kels JM, Halpern AC, Johnson TM, Sober AJ, Thompson JA, Wisco OJ, Wyatt S, Hu S, Lamina T (January 2019). "Guidelines of care for the management of primary cutaneous melanoma". J Am Acad Dermatol. 80 (1): 208–250. doi:10.1016/j.jaad.2018.08.055. PMID 30392755.
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Swetter SM, Tsao H, Bichakjian CK, Curiel-Lewandrowski C, Elder DE, Gershenwald JE, Guild V, Grant-Kels JM, Halpern AC, Johnson TM, Sober AJ, Thompson JA, Wisco OJ, Wyatt S, Hu S, Lamina T (January 2019). "Guidelines of care for the management of primary cutaneous melanoma". J Am Acad Dermatol. 80 (1): 208–250. doi:10.1016/j.jaad.2018.08.055. PMID 30392755.