Cutaneous melanoma

Scottish Intercollegiate Guidelines Network


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Prevention, surveillance and genetics

  • Information on preventing melanoma should be provided to the general public through a variety of media and resources
  • Healthcare professionals and members of the public should be aware of the risk factors for melanoma
  • Individuals identified as being at higher risk should be advised about appropriate methods of sun protection, educated about the diagnostic features of cutaneous melanoma and encouraged to perform self examination of the skin
  • Genetic testing for mutations in CDKN2A should be offered to an affected individual who has a first degree relative affected by melanoma or pancreatic cancer

Diagnosis and prognostic indicators

  • All patients with a diagnosis of melanoma should be discussed at a specialist multidisciplinary team meeting

Clinical diagnosis

  • Clinicians should be familiar with the 7-point or the ABCDE checklist for assessing lesions
  • Assess all pigmented skin lesions that are either referred for assessment or identified during follow up in secondary or tertiary care, using dermoscopy carried out by healthcare professionals trained in this technique
  • Health professionals should be encouraged to examine patients’ skin during other clinical examinations
  • Emphasis should be given to the recognition of early melanoma by both patients and health professionals

Educating health professionals about diagnosis

  • Targeted education can enhance health professionals' ability to diagnose melanoma

Biopsy of suspicious lesions

  • A suspected melanoma should be excised with a 2 mm margin and a cuff of fat
  • If complete excision cannot be performed as a primary procedure an incisional or punch biopsy of the most suspicious area is advised
  • A superficial shave biopsy is inappropriate for suspicious pigmented lesions
  • GPs should refer urgently all patients in whom melanoma is a strong possibility rather than carry out a biopsy in primary care
  • Newly-diagnosed patients should receive both verbal and written information about melanoma including the treatment options and support services available to them

Pathological diagnosis

Handling a suspected melanoma

  • The macroscopic description of a suspected melanoma should:
    • state the biopsy type, whether excision, incision, or punch
    • describe and measure the biopsy (in mm)
    • state the size of the lesion in mm and describe the lesion in detail (shape, pattern of pigment distribution, presence or absence of a nodular component and presence or absence of ulceration)
    • state the clearance of the lesion (in mm) from the nearest lateral margin and the deep margin
  • Selection of tissue blocks:
    • the entire lesion should be submitted for histopathological examination
    • the lesion should be sectioned transversely at 3 mm intervals and the blocks loaded into labelled cassettes
    • cruciate blocks should not be routinely selected (they limit the assessment of low power architectural features such as symmetry)
    • cruciate blocks may be used to assess margins in very large lentigo maligna excisions

Adjuvant treatment

Adjuvant radiotherapy for resected stage III melanoma

  • Consider adjuvant radiotherapy for patients with completely resected stage IIIB or IIIC melanoma after discussion of the risk of local recurrence and the benefits and risk of adjuvant therapy including risk of significant adverse effects

Interferon

  • Adjuvant interferon should not be used for patients with AJCC stage II and III melanoma other than in a trial setting

Immunosupression

  • All patients with melanoma and a history of immunosuppression should have a multidisciplinary team approach to care and minimising the immunosuppressive therapy should be considered where possible

Follow up

  • Patients who have had melanoma in situ do not require follow up
  • Patients should be given information and education on personal regular skin surveillance and nodal disease
  • Patients with an invasive melanoma should have a period of follow up

Psychological and emotional support

  • Follow up frequency and duration should take account of patients’ psychological and emotional needs

Surveillance imaging

  • Routine surveillance imaging should not be offered to patients with stage I-IIB melanoma
  • Decisions on the use of routine surveillance imaging for patients with stage IIC-III melanoma should be made at a regional managed clinical network level after identifying and agreeing any additional imaging resources required and considering other factors, including patient choice
  • CT should be used for surveillance imaging, if this is undertaken

Management of advanced (unresectable stage IIIC or IV) melanoma

  • All patients with advanced melanoma should be tested for mutations in BRAF and have their management discussed at a specialist multidisciplinary team in order to determine the optimal management strategy taking into account patient fitness, comorbidity, disease burden and overall aim of treatment
  • All patients with advanced melanoma should be offered the opportunity to participate in clinical trials

Surgery

  • Metastasectomy should be considered in patients with stage IV disease

Specialist palliative care

  • Patients with advanced melanoma require a co-ordinated multiprofessional approach with input from a specialist palliative care team
  • Patients with poorly controlled symptoms should be referred to specialist palliative care at any point in the cancer journey

Melanoma in women

Pregnancy

  • Women with a significant risk of recurrence (localised disease of ≥1 mm thickness) who wish to become pregnant after surgery for stage I or II melanoma should be advised to delay pregnancy for two years postsurgery, as the likelihood of recurrence is highest during this period
  • Pregnant women who present with growing or changing pigmented lesions should be treated as nonpregnant women

Oral contraceptive after melanoma treatment

  • Women who have had a melanoma treated should select contraception in the same way as women who have not had a melanoma

Hormone replacement therapy (HRT) after melanoma treatment

  • Women who have had stage I and II melanoma and who wish to take HRT should be treated as women who have not had melanoma

Information provision

  • Patients should receive targeted information throughout their journey of care
  • Healthcare professionals working with cancer patients should have training in communication skills
  • Communication skills training should be provided across the multidisciplinary team
  • Information needs should be resourced and provided using a variety of media, to meet individual patient/carer needs

Patient support groups

  • Health service patient support groups should be structured, facilitated by trained professionals and incorporate health education
  • Information on all patient support groups should be made easily available to patients

References

full guideline available from...
Scottish Intercollegiate Guidelines Network, Gyle Square, 1 South Gyle Crescent, Edinburgh EH12 9EB (Tel—0131 623 4720) sign.ac.uk/guidelines/fulltext/146/index.html

Scottish Intercollegiate Guideline Network. Cutaneous melanoma. Edinburgh: SIGN; 2017. (SIGN Guideline No.146).


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