From the academy
Guidelines of care for the management of primary cutaneous melanoma

https://doi.org/10.1016/j.jaad.2018.08.055Get rights and content

The incidence of primary cutaneous melanoma continues to increase each year. Melanoma accounts for the majority of skin cancer–related deaths, but treatment is usually curative following early detection of disease. In this American Academy of Dermatology clinical practice guideline, updated treatment recommendations are provided for patients with primary cutaneous melanoma (American Joint Committee on Cancer stages 0-IIC and pathologic stage III by virtue of a positive sentinel lymph node biopsy). Biopsy techniques for a lesion that is clinically suggestive of melanoma are reviewed, as are recommendations for the histopathologic interpretation of cutaneous melanoma. The use of laboratory, molecular, and imaging tests is examined in the initial work-up of patients with newly diagnosed melanoma and for follow-up of asymptomatic patients. With regard to treatment of primary cutaneous melanoma, recommendations for surgical margins and the concepts of staged excision (including Mohs micrographic surgery) and nonsurgical treatments for melanoma in situ, lentigo maligna type (including topical imiquimod and radiation therapy), are updated. The role of sentinel lymph node biopsy as a staging technique for cutaneous melanoma is described, with recommendations for its use in clinical practice. Finally, current data regarding pregnancy and melanoma, genetic testing for familial melanoma, and management of dermatologic toxicities related to novel targeted agents and immunotherapies for patients with advanced disease are summarized.

Key words

biopsy
follow-up
genetic counseling
imiquimod
melanoma
Mohs micrographic surgery
molecular techniques
pathology report
pregnancy
nonsurgical techniques
radiation therapy
sentinel lymph node biopsy
skin toxicities
surgical margins
staged excision
treatment

Abbreviations used

AAD
American Academy of Dermatology
AJCC
American Joint Committee on Cancer
ART
assisted reproductive technology
BRAFI
B-Raf proto-oncogene, serine/threonine kinase inhibitor
CPG
clinical practice guideline
CLND
completion lymph node dissection
CM
cutaneous melanoma
cSCC
cutaneous squamous cell carcinoma
CT
computed tomography
FDA
US Food and Drug Administration
GEP
gene expression profiling
HRT
hormone replacement therapy
LDH
lactate dehydrogenase
LN
lymph node
MAPK
mitogen-activated protein kinase
MBAIT
melanocytic BAP1-mutated atypical intradermal tumor
MEKI
mitogen-activated protein kinase kinase inhibitor
MIS, LM type
melanoma in situ, lentigo maligna type
MMS
Mohs micrographic surgery
MPM
multiple primary melanoma
MRI
magnetic resonance imaging
MSLT
Multicenter Selective Lymphadenectomy Trial
NCCN
National Comprehensive Cancer Network
OCT
oral contraceptive therapy
PAM
pregnancy associated melanoma
PD-1
programmed cell death protein 1
PD-L1
programmed death ligand 1
PET
positron emission tomography
RCT
randomized controlled trial
RCM
reflectance confocal microscopy
RT
radiation therapy
SLN
sentinel lymph node
SLNB
sentinel lymph node biopsy
WE
wide excision
WG
work group

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Funding sources: None.

Disclosure: The following information represents the authors' disclosed relationships with industry during guideline development. Relevant relationships requiring recusal for drafting of guideline recommendations and content by Work Group members are noted where applicable for each author. Hensin Tsao, MD, served as an advisory board member for Lubax and Epiphany Dermatology, receiving honoraria; in another role with Journal Watch Dermatology, receiving honoraria; and as a principal investigator for Relay Therapuetics, receiving grant funding. Clara Curiel-Lewandrowski, MD, served as a founder of DermSpectra LLC, receiving stock, and as a consultant for Amgen, receiving honoraria; she has a first-degree relative who received honoraria from Amendia. David E. Elder, MBChB, served as a consultant for SciBase and Myriad Genetics, receiving honoraria; he was recused from drafting recommendations related to adjunctive pathology tests for equivocal nevi. Jeffrey E. Gershenwald, MD, served as an advisory board member for Merck, Syndax Pharmaceuticals, and Castle Biosciences, receiving fees; and in another role for Mercator Therapeutics, receiving patent royalties; he was recused from drafting recommendations related to prognostic molecular tests. Jane M. Grant-Kels, MD, was a stockholder for Melafind; she was recused from drafting recommendations related to diagnostic imaging. Allan C. Halpern, MD, served as a consultant for Canfield Scientific, Inc, DermTech, International Janssen Research and Development LLC, and SciBase, receiving other financial benefits; as a member of the advisory board for Lucid, Inc, and Caliber Imaging and Diagnostics, receiving other financial benefits; and in another role for Quintiles Pharma, receiving other financial benefits. Dr Halpern was recused from drafting recommendations related to diagnostic imaging. Arthur J. Sober, MD, served as a principal investigator for MelaSciences, receiving grants/research funding; he was recused from drafting recommendations related to diagnostic imaging. John A. Thompson, MD, served as a consultant for Eisai Pharmaceuticals and Genentech, receiving honoraria; and as a member of the data safety monitoring board for Celldex, receiving honoraria. Oliver J. Wisco, DO, served as a consultant for MiMedx Group, Inc, and ClearPath Diagnostics, receiving fees. Dr Wisco was also a stockholder for MiMedx Group, Inc; he was recused from drafting recommendations on topic areas related to ClearPath products. Shasa Hu, MD, served as an advisory board member for Cosmetic Dermatology, receiving fees. Susan M. Swetter, MD, Christopher K. Bichakjian, MD, Valerie Guild, MS, MBA, Timothy M. Johnson, MD, Samantha Wyatt, MD, and Toyin Lamina, PhD, have no conflicts of interest to disclose.

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

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