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Primary Cutaneous Melanoma Clinical Practice Guidelines (2019)

 

Guidelines for the primary melanoma evaluation and treatment in 2019

 

 

In November 2018, the American Academy of Dermatology published Guidelines for the evaluation and  primary cutaneous melanoma treatment.

 

Israeli oncologists are evaluating and treating primary cutaneous melanoma in accordance with the international standards.

 

According to the latest data, the malignancy and the patient outcome can be predicted by the following important features:

 

  • Breslow level (depth)
  • Ulceration
  • Dermal mitotic rate.

 

First-line treatment for primary melanoma

 

Surgical excision with histologically negative edges is recommended as a first-line treatment for:

  • primary skin melanoma with any depth,
  • melanoma in situ.

The boundaries of the excision are determined by the depth level of the tumor.

 

The surgical field for invasive melanoma depends on the tumor size, and it is as follows:

 

  • minimum – 1 cm,
  • maximum – 2 cm,
  • less than 1 cm – if the surgical field can capture part of the anatomical structure.

Invasive melanoma excision is carried out as deeply as possible without capturing the fascia.

 

Patients surveillance with asymptomatic cutaneous melanoma or at 0-II stage

 

If primary melanoma is found for the first time and it is in the 0-2 stage, it is not recommended:

 

  • baseline radiologic imaging
  • laboratory research.

These studies are conducted only to assess signs in regional single, multiple or distant metastasis.

 

At the initial stage, it is recommended to observe lymph nodes with ultrasound, as well as:

 

  • with unclear or equivocal results of physical examination;
  • in patients with indices on a sentinel lymph node biopsy (SLNB) that was not performed;
  • if SLNB is impossible or technically unsuccessful to be conducted;
  • positive biopsy of the sentinel lymph node without dissection.

 

Strategies for detecting recurrent cutaneous melanoma

 

The most important tactic for detecting melanoma recurrence is regular follow-up. Additional radiological or laboratory tests are necessary to determine the disease spread to the lymph nodes and prescribed on the basis of:

 

  • patient history;
  • physical examination;
  • general condition.

 

Patients should learn self-examination of the skin surface and lymph nodes. It is one of the methods for identifying recurrent melanoma.

 

Patients with multiple squamoproliferative neoplasms should undergo a dermatological assessment:

 

  • immune checkpoint inhibitors – for the first month;
  • monotherapy with a BRAF inhibitor or MEK – every 2-4 weeks for 3 months.

Assessment by a dermatologist is carried out until the dermatological side effects disappear.

 

Source: Medscape, American Academy of Dermatology.

 

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