Guidelines for the Management of Cutaneous Melanoma 

June 1997

The Australian guidelines for melanoma management were prepared by the Australian Cancer Network (ACN) and are reproduced with permission of the ACN

Summary of Guidelines

PREVENTION

Avoid direct exposure to sunlight during the two hours either side of solar noon.

Use sun protective clothing when exposed to direct sunlight for periods greater than 15 minutes.

Use broad spectrum sunscreens with a minimum SPF of 15 as an adjunct to sun avoidance and other sun protective measures.

Provide and use sun protective structures (eg. shade structures) whenever possible.

Provide children with appropriate sun protection for outdoor activities.

Advise against the use of sunbeds, tanning booths and tanning lamps.

 

CLASSIFICATION OF MELANOMA

Use of the AJCC/UICC classification system is recommended.

 

CLINICAL DIAGNOSIS OF MELANOMA

Good lighting and magnification is recommended when lesions are being examined.

All clinicians should become trained in the recognition of early melanoma.

A good clinical history of the change in the lesion, if any, a past history of skin lesions, and a family history of melanoma should be obtained. A family history is defined as melanoma in a direct line family member- grandparent, parent, sibling or child of the patient.

Refer for specialist opinion or biopsy lesions which are suspicious or cannot be diagnosed after a period of observation.

High risk individuals should be advised on the specific changes which suggest melanoma and encouraged to undertake self examination

SURFACE MICROSCOPY

Training and experience with skin surface microscopy is recommended.

 

SCREENING AND SURVEILLANCE

People at very high risk of melanoma (eg. those with multiple dysplastic naevi or who have a history of melanoma in close relatives) should be advised on the specific changes which suggest melanoma, encouraged to undertake self examination, and offered a surveillance program.

Consider referral of these high risk individuals to a melanoma centre for inclusion in genetic studies.

 

FAMILIAL RISK AND FAMILY SURVEILLANCE

Consider referral of family members with a strong history of melanoma among close relatives, particularly with large numbers of naevi, to a melanoma centre for genetic studies.

 

BIOPSY OF PIGMENTED LESIONS

Biopsy of pigmented lesions should be done only on the basis of suspicious clinical features. Prophylactic excision of clinically benign lesions is not recommended.

Where doubt exists, a period of observation based on the history and clinical features of the lesion is acceptable. The period of observation will be short if a high level of suspicion of melanoma is present. However, if the clinician feels the lesion is unlikely to be melanoma and it does not change, it is appropriate to continue observation until the evidence of change appears.

If melanoma is suspected, referral for a specialist opinion, where available, should be considered before biopsy is undertaken.

Shave and punch biopsies of pigmented lesions should be avoided if excision biopsy with primary skin closure can be achieved.

Lesions suspected to be melanoma should be excised with a 2mm lateral margin and to the depth of the upper layer of the fat.

 

CONGENITAL MELANOCYTIC NAEVI

Monitor all congenital lesions >20cm in diameter for the lifetime of the person.

Excisional biopsy of suspicious areas in large congenital naevi is recommended.

Surgical excision of congenital naevi is appropriate where patient concern is high and where an acceptable cosmetic outcome can be achieved.

 

LENTIGO MALIGNA

Biopsy is indicated for changing pigmented lesions on the face.

Where lentigo maligna is histologically confirmed, complete excision is the preferred management.

For some patients, treatment by observation for change, with measurement, is an acceptable alternative to immediate excision.

A Woods light is helpful to determine the extent of the lentigo maligna.

 

HISTOPATHOLOGICAL REPORT

Request forms for pathology should include adequate patient identification, and clinical details of all lesions removed.

Where more than one lesion is excised, separate specimen bottles are essential.

The pathologist's report should include all important features of the lesions (Appendix D). Tumour thickness, Clark level and clearance margins are essential.

Where clinical and pathological diagnoses do not concur, a second opinion should be sought from a pathologist with expertise in the diagnosis of pigmented tumours.

 

TREATMENT OF PRIMARY MELANOMA

The AJCC/UICC system is recommended as the basis for melanoma therapy.

Complete excision with margins determined by tumour thickness measurement should be the basis for management of primary melanoma.

A minimum margin of 1cm and a maximum margin of 3cm should be used for invasive melanoma, with the choice of excision margin determined by tumour thickness. A depth of excision equal to margins is advised but it is not necessary to excise further than the deep fascia.

A margin of excision of 5mm is recommended for melanoma in-situ.

Other pathological features should be used to make an assessment of prognosis and modify management decisions.

 

TREATMENT OF LYMPH NODES

Needle aspiration is preferable to excision biopsy of lymph nodes suspicious of metastatic melanoma.

Excision biopsy of suspicious nodes should be followed by node dissection immediately if nodal metastases are detected.

Elective lymph node dissection is generally not recommended for every melanoma patient.

Elective node dissection may have a place for specific subsets of patients.

Therapeutic node dissection should be undertaken only by surgeons trained in these procedures.

Lymphatic mapping and sentinel node biopsy should be considered for all melanomas >1mm thick provided it can be done in the context of a controlled clinical trial and by surgeons trained in these procedures.

 

OCCULT PRIMARY MELANOMA

Melanoma in lymph nodes or systemic metastases should be treated appropriately regardless of the inability to detect the primary lesions.

 

LOCOREGIONAL RECURRENT MELANOMA

Excision of a single local or regional metastasis is the treatment of choice.

Patients with multiple local metastases should be referred to a centre specialising in regional therapy ie. perfusion or infusion with cytotoxic agents.

 

ADJUVANT THERAPY

Patients with melanomas >4mm thick or with lymph node metastases should be referred to a melanoma centre for consideration of adjuvant therapy.

 

DISSEMINATED MELANOMA

Patients with systemic metastases should be referred to a melanoma centre for consideration of systemic therapies.

All clinicians dealing with patients with systemic melanoma should be appropriately skilled in psychological management and palliative care.

Surgical resection should be considered for isolated melanoma metastases in lung, brain and peritoneal cavity.

 

RADIOTHERAPY FOR MELANOMA

Postoperative radiotherapy should be considered for melanomas likely to recur locally (>4mm thick, with satellite nodules or neurotropic spread) or regionally (multiple node involvement or extracapsular spread) and following resection of mucosal melanomas. Primary radiotherapy should be considered for unresectable lentigo maligna melanomas.

Radiotherapy is recommended for treatment of extensive cutaneous metastases and for palliative management of cerebral and bone metastases and for other metastases where temporary local control is needed eg. large nodal or soft tissue masses.

 

FOLLOW-UP

A follow-up regimen based on tumour thickness should be arranged for all patients with invasive melanomas.

The follow-up examination should include palpation for local recurrence, in-transit metastases, lymph node fields and a general examination of the skin for new primary melanomas and other skin cancers.

 

APPROPRIATE INVESTIGATIONS

Extensive investigation for systemic metastases in patients with primary melanoma is not recommended.

Investigations such a CT, MRI and PET should be utilised only where specific symptoms suggest the presence of metastases.

 

SPECIFIC SITES AND TYPES OF MELANOMA

a. Mucosal melanoma

Patients with mucosal melanoma should be referred to a suitable speciality clinic or clinician.

b. Acral lentiginous melanoma (ALM)

ALM on the sole of the foot should be referred for specialist excision and appropriate reconstructive procedures.

c. Subungual melanoma

Subungual melanoma should be considered as a possible cause of any pigmentary changes under the nail. In cases of doubt, removal of the nail and biopsy is recommended.

Subungual melanoma should be treated with excision margins which accord to the lesion thickness. This usually involves amputation of the terminal phalanx.

d. Desmoplastic melanoma

Wider excision than is normal for other histological types of melanoma is recommended for desmoplastic melanoma.

Postoperative radiotherapy, in consultation with a melanoma centre should be considered after surgical excision of a recurrent desmoplastic or neurotropic melanoma.

e. Multiple primary melanoma

Multiple primary melanoma should be treated according to the tumour thickness of each lesion.

f. Melanoma in childhood

Melanoma in children should be treated as appropriate for the same tumour thickness melanoma in the adult.

g. Melanoma during pregnancy

Melanoma in a pregnant woman should be treated according to the tumour thickness.

Pregnant women with thicker melanomas and nodal metastases should be treated in consultation with specialised centres and psychological support may need to be obtained.

Because of the possibility of metastatic recurrence, pregnancy is not advisable for two years after removal of high risk primary melanoma or melanoma in nodes.

Termination of pregnancy should be considered in women with high risk primary or recurrent melanoma only after detailed discussion with the patient and her partner.

h. Hormone replacement therapy and oral contraceptives

Hormone replacement therapy and oral contraceptives are not contraindicated for women who have or have had melanoma.

Multiple copies of the 'Guidelines' may be obtained through the Australian Cancer Network, GPO Box 4708, Sydney NSW 2001, Australia, tel: 61 2 9368 0002. Single copies may be obtained through The Melanoma Foundation by faxing your details to: 61 2 9550 6316.