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Guideline Summary
Guideline Title
Revised U.K. guidelines for the management of cutaneous melanoma 2010.
Bibliographic Source(s)
Marsden JR, Newton-Bishop JA, Burrows L, Cook M, Corrie PG, Cox NH, Gore ME, Lorigan P, MacKie R, Nathan P, Peach H, Powell B, Walker C, British Association of Dermatologists Clinical Standards Unit. Revised U.K. guidelines for the management of cutaneous melanoma 2010. Br J Dermatol. 2010 Aug;163(2):238-56. [143 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Roberts DL, Anstey AV, Barlow RJ, Cox NH, Newton Bishop JA, Corrie PG, Evans J, Gore ME, Hall PN, Kirkham N. U.K. guidelines for the management of cutaneous melanoma. Br J Dermatol 2002 Jan;146(1):7-17. [60 references]

Scope

Disease/Condition(s)

Cutaneous melanoma

Guideline Category
Diagnosis
Management
Prevention
Risk Assessment
Screening
Treatment
Clinical Specialty
Dermatology
Family Practice
Internal Medicine
Obstetrics and Gynecology
Oncology
Pathology
Plastic Surgery
Radiation Oncology
Surgery
Intended Users
Advanced Practice Nurses
Health Care Providers
Nurses
Physician Assistants
Physicians
Guideline Objective(s)
  • To provide best practice recommendations for the management of cutaneous melanoma
  • To present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiology, diagnosis, investigation, and follow up
Target Population
  • Individuals in the general population (prevention)
  • Individuals at high risk of melanoma (screening and surveillance)
  • Patients with lesions which are suspicious for melanoma
  • Patients with cutaneous melanoma
Interventions and Practices Considered

Prevention and Screening/Surveillance

  1. Screening and surveillance of high risk individuals
  2. Self examination
  3. Prophylactic excision
  4. Referral to a clinical geneticist or specialized dermatology service
  5. Referral to specialists
  6. Monitoring of high-risk individuals for malignant changes

Clinical Assessment

  1. History (the presence or absence of these changes should be recorded)
    • Duration of the lesion
    • Change in size
    • Change in color
    • Change in shape
    • Symptoms (itching, bleeding, etc.)
  2. Examination
    • Site
    • Size (maximum diameter)
    • Elevation (flat, palpable, nodular)
    • Description (irregular margins, irregular pigmentation and if ulceration is present)
  3. Biopsy of suspected melanoma
  4. Histopathology
  5. Pathological staging
  6. Sentinel lymph node pathology
  7. Investigations and imaging based on pathological staging

Treatment/Management

  1. Surgical excision, with surgical margins based on Breslow thickness
  2. Management of lymph node basins
  3. Management of clinically node-negative patients
  4. Management of patients with clinically or radiologically suspicious lymph nodes
  5. Management of patients with confirmed positive lymph node metastasis
  6. Management of locoregional recurrent melanoma
    • Ultrasound and fine needle aspiration cytology (FNAC) prior to block dissection
    • Computed tomographic scan prior to lymph node dissection
    • Carbon dioxide laser
    • Isolated limb perfusion or infusion
  7. Metastasectomy in selected patients who relapse with oligometastatic disease
  8. Surgery for selected sites such as the skin, brain or bowel
  9. Palliative therapy
  10. Adjuvant and palliative radiotherapy
  11. Chemotherapy with dacarbazine
  12. Management of melanoma patients who are pregnant or using hormone replacement therapy or oral contraceptives
  13. Use of immunosuppressants after melanoma
  14. Follow-up according to type and stage of melanoma
Major Outcomes Considered
  • Risk of melanoma
  • Survival
  • Disease recurrence
  • Disease remission
  • Mortality

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

PubMed literature searches for this guidelines revision were carried out to identify publications from 2000 to April 2010, with search terms including: melanoma genetics, epidemiology, early diagnosis, risk factors, clinical features, pathology, surgery, chemotherapy and clinical trials. Relevant materials were also isolated from reviews and other publications identified from the PubMed searches, independent searches carried out by the authors, as well as materials collected by the authors as part of their ongoing professional interest in the latest developments in this clinical area.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Level of Evidence

Ia - Evidence obtained from meta-analysis of randomized controlled trials, or meta-analysis of epidemiological studies

Ib - Evidence obtained from at least one randomized controlled trial

IIa - Evidence obtained from at least one well-designed controlled study without randomization

IIb - Evidence obtained from at least one other type of well-designed quasi-experimental study

III - Evidence obtained from well-designed nonexperimental descriptive studies, such as comparative studies, correlation studies and case studies

IV - Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Grade of Recommendation

  1. There is good evidence to support the use of the procedure.
  2. There is fair evidence to support the use of the procedure.
  3. There is poor evidence to support the use of the procedure.
  4. There is fair evidence to support the rejection of the use of the procedure.
  5. There is good evidence to support the rejection of the use of the procedure.
Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

These guidelines were initially reviewed at a multidisciplinary meeting on 8 November 2007. The reviewers are acknowledged in the original guideline document.

Recommendations

Major Recommendations

Definitions for the levels of evidence (Ia-IV) and grades of recommendations (A-E) are presented at the end of the "Major Recommendations" field.

Prevention of Melanoma

Individuals, and particularly children, should not get sunburnt (Level I). Meta-analysis of case–control studies provides good evidence that melanoma is caused predominantly by intermittent intense sun exposure; fair-skinned individuals should therefore limit their recreational exposure through life (Level I).

There is evidence from a recent meta-analysis that sunbed usage does increase the risk of melanoma, particularly under the age of 35 years, and therefore it is recommended that this should be avoided (Level Ia).

Referral and Clinical Diagnosis

Melanoma Patients Who Must Be Referred from the Local Skin Cancer Multidisciplinary Team to the Specialist Skin Cancer Multidisciplinary Team (SSMDT)

  • Patients with melanoma managed by other site specialist teams, e.g., gynaecological, mucosal and head and neck (excluding ocular)
  • Patients with stage IB or higher primary melanoma when sentinel lymph node biopsy (SLNB) is available within their Network. In the absence of SLNB then patients with stage IIB or higher should be referred to the SSMDT (American Joint Committee on Cancer staging system)
  • Patients with melanoma at any stage who are eligible for clinical trials that have been approved at Cancer Network level
  • Patients with multiple primary melanomas
  • Children and young adults younger than 19 years with melanoma
  • Any patient with metastatic melanoma diagnosed at presentation or on follow up
  • Patients with giant congenital naevi where there is suspicion of malignant transformation
  • Patients with skin lesions of uncertain malignant potential

Lesions which are suspicious for melanoma should not be removed in primary care. This is because clinicopathological correlation is vital for diagnostic accuracy, which in turn determines prognosis and defines adjuvant treatment options, and because diagnostic surgery requires specialist training. Early recognition of melanoma presents the best opportunity for cure (Level III, Grade A).

All patients presenting with an atypical melanocytic lesion or a large number of moles should have a complete skin examination and assessment of risk factors. The dermoscope is a useful tool for the trained clinician screening pigmented lesions, as it can increase diagnostic accuracy. It is also useful for monitoring multiple pigmented lesions where photography of dermoscopic images provides a record of change (Level Ia, Grade A).

Recommendations for Local Skin Cancer Multidisciplinary Team Record Keeping of Clinical Features

As a minimum the following should be included:

  • History (the presence or absence of these changes should be recorded)
    • Duration of the lesion
    • Change in size
    • Change in colour
    • Change in shape
    • Symptoms (itching, bleeding etc.)
  • Examination
    • Site
    • Size (maximum diameter)
    • Elevation (flat, palpable, nodular)
    • Description (irregular margins, irregular pigmentation and if ulceration is present) (Level III, Grade B)

Screening and Surveillance of High-Risk Individuals

All individuals at increased risk of melanoma should be advised on the specific changes that suggest melanoma and encouraged to undertake monthly skin self-examination (Level III, Grade B). Close-up and distant photography may be a useful adjunct to detecting early melanoma in either of these high-risk groups (Level III). They should be given written information and access to images of moles and melanomas.

Recommendations for Screening and Surveillance of High-Risk Individuals

  • Patients who are at moderately increased risk of melanoma should be advised of this and taught how to self-examine. This includes patients with atypical mole phenotype, those with a previous melanoma, and organ transplant recipients (Level Ia, Grade B).
  • Patients with giant congenital pigmented naevi are at increased risk of melanoma and require long-term follow up (Level IIIa, Grade B).
  • Individuals with a family history of three or more cases of melanoma, or of pancreatic cancer, should be referred to a clinical geneticist or specialized dermatology services for counselling. Those with two cases in the family may also benefit, especially if one of the cases had multiple primary melanomas or the atypical mole phenotype (Level IIa, Grade B).

Biopsy of Suspected Melanoma

A lesion suspected to be melanoma, or where melanoma needs to be excluded, should be photographed, and then excised completely. The axis of excision should be orientated to facilitate possible subsequent wide local excision; generally on the limb this will be along the long axis. If uncertain, direct referral to the multidisciplinary team (MDT) will allow appropriate planning for future surgery. The excision biopsy should include the whole tumour with a clinical margin of 2 mm of normal skin, and a cuff of fat. This allows confirmation of the diagnosis by examination of the entire lesion, such that subsequent definitive treatment can be based on Breslow thickness.

Diagnostic shave biopsies should not be performed as they may lead to incorrect diagnosis due to sampling error, and make accurate pathological staging of the lesion impossible (Level III). For the same reasons partial removal of naevi for diagnosis must be avoided and partial removal of a melanocytic naevus may result in a clinical and pathological picture very like melanoma (pseudomelanoma). This gives rise to needless anxiety and is avoidable. Incisional or punch biopsy is occasionally acceptable, for example in the differential diagnosis of lentigo maligna (LM) on the face or of acral melanoma, but there is no place for either incisional or punch biopsy outside the skin cancer MDT (Level III). It is acceptable in certain circumstances to excise the lesion entirely but without repair, and to dress the wound while awaiting definitive pathology.

Biopsies of possible subungual melanomas should be carried out by surgeons regularly doing so. The nail should be removed sufficiently for the nail matrix to be adequately sampled: clinically obvious tumour should be biopsied if present. Prophylactic excision of naevi, or of small (<5 cm diameter) congenital naevi in the absence of suspicious features is not recommended (Level III, Grade D).

Full clinical details should be supplied on the histopathology form, including history of the lesion, relevant previous history, site and differential diagnosis. All melanocytic lesions excised for whatever reason must be sent for histopathological review to the pathologist associated with the Local Skin Cancer Multidisciplinary Team (LSMDT) or SSMDT.

The diagnosis of melanoma, both in situ and invasive, should be given or supervised by doctors who have received advanced communication skills training, following local policies for breaking bad news. A skin cancer trained nurse should be present to provide continuing support.

Histopathology

General Comments

The Royal College of Pathologists has produced a minimum dataset which should be included in the histopathology report. Double reporting is recommended for all melanomas and all naevi showing severe dysplasia if resources allow this to be achieved within 14 days.

The Histopathology Report

The report should include the following:

Clinical Information

  • Site of the tumour
  • Type of surgical procedure: excision or re-excision, incision biopsy, punch biopsy
  • Any other relevant clinical information

Macroscopic Description

Contour, colour and size of the tumour and the excised skin specimen in millimetres.

Microscopy

  • Presence or absence of ulceration
  • Thickness - In the presence of histological regression thickness measurements should be of the residual melanoma. Microsatellites should not be included in thickness measurements (Level III, Grade B).
  • Mitotic count
  • Histological subtypes
  • Margins of excision
  • Pathological staging
  • Growth phase
  • Regression
  • Tumour-infiltrating lymphocytes
  • Lymphatic or vascular invasion
  • Perineural infiltration
  • Microsatellites
  • Precursor naevus
  • Clark level of dermal invasion

Sentinel Lymph Node Pathology

Pathological Assessment

This needs to be done in a standardized way so that findings between centers are comparable (Level III, Grade B).

Dissection

The dissection should be either by bivalving or multiple slicing, although the former is recommended. A minimum of six serial sections should be taken, but a higher incidence of metastases is detected by extended step sectioning with immunohistochemistry at each level.

Staining

Use of haematoxylin and eosin and immunohistochemistry is essential. S100 and Melan A are most favoured immunohistochemical stains but a composite method such as PanMel is also appropriate.

Assessment of Tumour Burden

This gives additional prognostic information. The following are recommended:

Assessing the depth of the metastasis from the inner aspect of the sentinel lymph node capsule; categorizing the metastasis according to its site, either subcapsular or parenchymal; measuring the maximum dimension of the largest confluent group of melanoma cells.

Completion Lymphadenectomy Specimens

The pathological examination of regional nodes dissected following positive SLNB should include an attempt to examine all lymph nodes at least at one level, and count the number involved. The presence of extracapsular spread and involvement of perinodal fat should be recorded together with the size of the tumour-free margin. The use of immunohistochemistry such as S100 or Melan A facilitates this.

Investigations and Imaging

Stage I and II Melanoma

Routine investigations are not required for asymptomatic patients with primary melanoma. Blood tests are unhelpful.

Routine computed tomography (CT) is not recommended for patients with stage I and II melanoma as this has a very low incidence of true-positive and high incidence of false-positive findings. Patients with particularly high-risk primary melanoma may undergo staging investigations if deemed appropriate by the SSMDT and/or as a prerequisite to trial entry. There is no indication for routine imaging with any other modality including plain X-ray, positron emission tomography (PET)/CT and magnetic resonance imaging (MRI). PET/CT is not effective in detecting positive sentinel lymph nodes and/or distant metastases in patients with primary melanoma (Level IIa, Grade E).

Sentinel Lymph Node Biopsy and Ultrasound/Fine Needle Aspiration Cytology

SLNB, as discussed later, has high sensitivity and specificity for diagnosing subclinical regional lymph node involvement.

Ultrasound and fine needle aspiration cytology (FNAC) is the next best method but quoted sensitivities range from 4.7% to 80%, with the higher sensitivities being achieved only by sentinel node mapping and FNAC of the sentinel node in all cases regardless of morphological appearance. Further staging by CT imaging following a positive sentinel lymph node, and prior to completion lymphadenectomy, has a very low yield. Consequently this should be done only after discussion with an informed patient and the SSMDT (Level IIa, Grade D).

Stage III and IV Melanoma

In stage III and IV melanoma, imaging strategies will be planned by the SSMDT.

CT scanning of the head, chest, abdomen and pelvis will normally adequately exclude metastases, and is most relevant in stage III melanoma before planning regional lymph node dissection (LND) and regional chemotherapy. If patients are considering entry to an adjuvant study following lymphadenectomy, the timing of scans should be determined by the SSMDT to avoid duplication. When stage IV disease is suspected clinically, CT scanning of the head and whole body should be considered. Further imaging will be determined by symptoms, clinical trial protocols, and for clarification or reassessment of previous imaging findings. Generally, the added yield of PET/CT is unlikely to be clinically relevant in established stage IV melanoma (Level III, Grade D).

Staging Investigations for Melanoma

  • Patients with stage I, II and IIIA melanoma should not routinely be staged by imaging or other methods as the true-positive pick-up rate is low and the false-positive rate is high (Level IIa, Grade E)
  • Patients with stage IIIB or IIIC melanoma should be imaged by computed tomography of head, chest, abdomen and pelvis prior to surgery after SSMDT review (Level IIa, Grade A)
  • Patients with stage IV melanoma should be imaged according to clinical need and SSMDT review. Lactate dehydrogenase should also be measured (Level III, Grade A)

Treatment of the Primary Lesion

Surgery is the only curative treatment for melanoma. Following excision for diagnosis and for measurement of microscopic Breslow thickness, a wider and deeper margin is taken to ensure complete removal of the primary lesion, and to remove any micrometastases. The depth of the therapeutic excision has conventionally been to the muscle fascia or deeper, and there is no evidence to support altering this approach.

Recommended Surgical Excision Margins (Summary)

Breslow Thickness Excision Margins Level of Evidence Grading of Evidence
In situ 5-mm margins to achieve complete histological excision III B
<1 mm 1 cm Ib A
1.01–2 mm 1–2 cm Ib A
2.1–4 mm 2–3 cm Ib A
>4 mm 3 cm Ib B

Management of Lymph Node Basins

Investigation and management of lymph node basins in melanoma patients should be carried out by SSMDTs so that surgical treatment planning and investigations can run in parallel. There is no place for elective LND in the management of primary melanoma unless this is unavoidable because the primary melanoma lies over the lymph node basin (Level Ib, Grade A). Patients should have access to a skin cancer specialist nurse when relapse is suspected.

Recommendations for the Management of Clinically Node-Negative Patients

  • There is no role for elective lymph node dissection (Level I, Grade E)
  • SLNB can be considered in stage IB melanoma and upwards in Specialist Skin Cancer Multidisciplinary Teams (Level Ia, Grade A)
  • Patients should be introduced to the concept of SLNB as a staging procedure but should also understand that it has no proven therapeutic value
  • Surgical risks of SLNB, the possibility of failure to find a sentinel lymph node, and of a false-negative result, should also be explained

Management of Patients with Clinically or Radiologically Suspicious Lymph Nodes

FNAC of nodes is recommended when there is clinical doubt about the significance of the nodes. If there is a negative FNAC result but ongoing suspicion, then the fine needle aspiration should be repeated or an image-guided core biopsy arranged.

Open biopsy is recommended when there is clinical suspicion even in the presence of negative FNACs in which lymphocytes have been successfully aspirated. If open biopsy is performed, the incision must be such as to allow subsequent complete formal block dissection of the regional nodes without compromise. It should be done only by SSMDT members.

Exploration or removal of a mass within a nodal basin which drains a known primary melanoma site, and prior to definitive surgical treatment, may increase the risk of melanoma recurrence in that basin. Any melanoma patient who develops a mass in a nodal basin should be referred urgently to the SSMDT, and without prior investigation, for investigation and treatment planning (Level III, Grade B).

Management of Patients with Confirmed Positive Lymph Node Metastasis

Radical LND should be performed only by SSMDT members who do a combined minimum of 15 axillary and groin block dissections for skin cancer each year.

Preoperative staging investigations should be carried out as already discussed for stage III melanoma. If such staging is not feasible prior to surgery, and surgery is considered necessary even if distant metastatic disease were to be detected, then a chest X-ray and lactate dehydrogenase (LDH) measurement is recommended.

The block dissection specimen should be marked and orientated for the pathologist. Axillary LND for melanoma should include all nodes in levels I–III, and this may require either resection or division of pectoralis minor. The management of inguinal lymph node metastases is controversial.

A superficial inguinal LND should be considered in the presence of:

  • A single clinically involved inguinal node or femoral triangle node
  • A single positive superficial inguinal sentinel node (Level Ib, Grade A)

A pelvic lymph node dissection should be considered in the presence of:

  • More than one clinically palpable inguinal and/or femoral triangle node/s
  • CT or ultrasound evidence of more than one inguinal and/or femoral triangle node/s, or of pelvic node involvement
  • More than one microscopically involved node at SLNB
  • A conglomerate of inguinal or femoral triangle lymph nodes
  • Microscopic or macroscopic involvement of Cloquet's node (Level III, Grade B)

Cervical nodal recurrence should be treated either by surgeons in the SSMDT specializing in head and neck skin cancer including melanoma or by a head and neck MDT with a special interest in melanoma. A comprehensive, and not a selective, neck dissection should be performed (Level III, Grade A).

Locoregional Recurrent Melanoma: Skin and Soft Tissues

Surgery is the treatment of choice for single local or regional metastases. Excision should be clinically and histologically complete, but a wide margin is not required. Multiple small (<1 cm) dermal lesions respond well to treatment with the CO2 laser. Dermal disease which is progressing despite surgery or laser, and subcutaneous or deeper limb metastases, should be considered for regional chemotherapy with isolated limb infusion (ILI) with melphalan and actinomycin D, or with isolated limb perfusion (ILP) (Level IIb, Grade B).

Recommendations for Locoregional Recurrent Melanoma

  • Nodes clinically suspicious for melanoma should be sampled using fine needle aspiration cytology (FNAC) prior to carrying out formal block dissection. If FNAC is negative although lymphocytes were seen, a core or open biopsy should be performed if suspicion remains (Level III, Grade B)
  • Prior to lymph node dissection, performed by an expert, staging by computed tomographic scan should be carried out other than where this would mean undue delay (Level III, Grade B)
  • The treatment of locoregional recurrence in a limb is palliative. Surgical excision, CO2 laser, or isolated limb infusion or perfusion may be considered (Level IIb, Grade B)

Adjuvant Therapy

There is no evidence of a survival benefit for adjuvant chemotherapy in patients with melanoma. This includes adjuvant regional chemotherapy using ILP, and therefore ILI.

Interferon is not recommended as standard of care for adjuvant therapy of primary or stage III melanoma (Level Ia, Grade A).

Patients should be offered entry into adjuvant clinical trials approved by the local Cancer Network.

Adjuvant Radiotherapy

If there is clinical or histological doubt about the adequacy of surgery following recurrence, or about the feasibility of salvage surgery, adjuvant radiotherapy may be considered by the SSMDT (Level Ib, Grade B).

Occult Primary Melanoma

Patients with occult primary melanoma may present with a solitary metastasis, lymph node disease, or systemic disease. Such patients should be referred promptly to the SSMDT for investigation and treatment planning.

Patients presenting with lymph node disease from an occult primary involving a single lymph node basin should be presumed to have regional rather than distant metastasis, and treated as for stage III disease with lymph node block dissection.

Metastatic Disease

The benefits of treating patients with cerebral metastases with whole-brain radiotherapy are limited, but this may sometimes have palliative value. Supportive care is therefore the most appropriate strategy for many patients (Level IIb, Grade B).

Spinal cord compression should be treated surgically if feasible, but multiple sites of disease, poor prognosis and poor performance status may make this inappropriate. Radiotherapy may be useful for palliation of rapidly enlarging or painful metastases involving soft tissues and bones (Level IIb, Grade B)

Recommendations for Metastatic Disease

  • All patients should be managed by Specialist Skin Cancer Multidisciplinary Teams
  • Surgery should be considered for oligometastatic disease at sites such as the skin, brain or bowel (Level IIb, Grade B), or to prevent pain or ulceration
  • Radiotherapy may have a palliative role in the treatment of metastases (Level II, Grade B)
  • Standard chemotherapy is dacarbazine although its role is palliative (Level II, Grade C)
  • Patients with stage IV melanoma should be considered for entry to clinical trials

Melanoma, Hormone Replacement Therapy and Pregnancy

Surgical treatment should be determined in the normal way, but the risks of exposure to ionizing radiation and blue dye during sentinel node biopsy will need special consideration.

There is no medical reason to justify delaying conception after a diagnosis of melanoma (Level IIa) but the social and family effects of developing recurrent melanoma during pregnancy or after birth are great.

Recommendations Regarding Pregnancy and Hormone Replacement Therapy

Pregnancy with Primary Melanoma

  • No worsening of prognosis
  • No increase in adverse outcomes for mother or baby

Pregnancy in Advanced Melanoma

  • Placental and fetal metastases possible in stage IV disease

Oral Contraceptives and Melanoma

  • No increased risk of melanoma

Hormone Replacement Therapy

  • No increased risk of melanoma
  • No worsening of prognosis

Use of Drugs in Melanoma Patients

The use of immunosuppressants after melanoma is a cause for concern. However, there is usually little that can be done to avoid these drugs without an unacceptable loss of quality of life. Their use after treatment of primary or secondary melanoma should be discussed between the prescribing doctors and patients, and the decision to continue their use and their dosage should be subject to ongoing review following a diagnosis of melanoma (Level III, Grade C).

Organ and Blood Donation

The decision about whether organs or tissue are suitable for transplant is made on an individualized basis, taking into account the patient's medical history. A melanoma patient would not normally be considered as a donor.

Follow-up

Sentinel Lymph Node Biopsy

Patients who have had a negative SLNB should be followed up on the basis of Breslow thickness. Most patients who have had a positive SLNB will have had a completion lymphadenectomy. As these patients now have at least stage IIIA disease, their follow up should be supervised by the SSMDT, and entry into appropriate trials considered. Risk of recurrence depends on extent of sentinel lymph node involvement, and may be less than for some with stage II melanoma. They should be followed up as for stage IB–IIC melanoma (Level III, Grade B).

Follow-up of Melanoma Patients

  • Patients with in situ melanomas do not require follow up
  • Patients with invasive melanomas have differing risk of relapse according to their stage group
  • Patients with stage IA melanoma should be seen two to four times over up to 12 months, then discharged
  • Patients with stage IB–IIIA melanoma should be seen 3-monthly for 3 years, then 6-monthly to 5 years
  • Patients with stage IIIB and IIIC and resected stage IV melanoma should be seen 3-monthly for 3 years, then 6-monthly to 5 years, then annually to 10 years
  • Patients with unresectable stage IV melanoma are seen according to need

(Level III, Grade B)

Definitions:

Level of Evidence

Ia - Evidence obtained from meta-analysis of randomized controlled trials, or meta-analysis of epidemiological studies

Ib - Evidence obtained from at least one randomized controlled trial

IIa - Evidence obtained from at least one well-designed controlled study without randomization

IIb - Evidence obtained from at least one other type of well-designed quasi-experimental study

III - Evidence obtained from well-designed nonexperimental descriptive studies, such as comparative studies, correlation studies and case studies

IV - Evidence obtained from expert committee reports or opinions and⁄or clinical experience of respected authorities

Grade of Recommendation

  1. There is good evidence to support the use of the procedure.
  2. There is fair evidence to support the use of the procedure.
  3. There is poor evidence to support the use of the procedure.
  4. There is fair evidence to support the rejection of the use of the procedure.
  5. There is good evidence to support the rejection of the use of the procedure.
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for selected recommendations (see "Major Recommendations").

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate management of patients with cutaneous melanoma

Potential Harms
  • Side effects of treatment
  • The use of immunosuppressants after melanoma is a cause for concern. The results of a recent cohort study of patients with rheumatoid arthritis treated with biologic agents showed an increased risk of melanoma (odds ratio 2.3, 95% confidence interval 0.9–5.4). However, there is usually little that can be done to avoid these drugs without an unacceptable loss of quality of life. Their use after treatment of primary or secondary melanoma should be discussed between the prescribing doctors and patients, and the decision to continue their use and their dosage should be subject to ongoing review following a diagnosis of melanoma.

Contraindications

Contraindications
  • In pregnancy, staging using X-rays should be avoided where possible especially in the first trimester. Magnetic resonance imaging should be used in preference to computed tomography scan where feasible.
  • Use of chemotherapy agents in the first trimester should be avoided.

Qualifying Statements

Qualifying Statements
  • These guidelines reflect the best data available at the time the report was prepared. Caution should be exercised in interpreting the data; the results of future studies may require alteration of the conclusions or recommendations in this report. It may be necessary or even desirable to depart from the guidelines in the interests of specific patients and special circumstances. Just as adherence to the guidelines may not constitute defence against a claim of negligence, so deviation from them should not necessarily be deemed negligent.
  • The intention of the working party was to agree best practice for the management of melanoma in the belief that this will promote good standards of care across the whole country. However, they are guidelines only. Care should be individualized wherever appropriate.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Audit Criteria/Indicators
Patient Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Marsden JR, Newton-Bishop JA, Burrows L, Cook M, Corrie PG, Cox NH, Gore ME, Lorigan P, MacKie R, Nathan P, Peach H, Powell B, Walker C, British Association of Dermatologists Clinical Standards Unit. Revised U.K. guidelines for the management of cutaneous melanoma 2010. Br J Dermatol. 2010 Aug;163(2):238-56. [143 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2002 Jan (revised 2010 Aug)
Guideline Developer(s)
British Association of Dermatologists - Medical Specialty Society
Source(s) of Funding

British Association of Dermatologists

Guideline Committee

British Association of Dermatologists Therapy & Guidelines and Audit & Clinical Standards Subcommittees

Composition of Group That Authored the Guideline

Primary Authors: J.R. Marsden, University Hospital Birmingham, Birmingham; J.A. Newton-Bishop, University of Leeds, Leeds; L. Burrows, Salisbury District Hospital, Salisbury; M. Cook, Royal Surrey County Hospital NHS Trust, Guildford; P.G. Corrie, Cambridge University Hospitals NHS Foundation Trust, Cambridge; N.H. Cox, Cumberland Infirmary, Carlisle; M.E. Gore, Royal Marsden Hospital, London; P. Lorigan, The Christie NHS Foundation Trust, Manchester; R. MacKie, University of Glasgow, Glasgow; P. Nathan, Mount Vernon Hospital, London; H. Peach, St James's University Hospital, Leeds; B. Powell, St George's Hospital, London; and C. Walker, University Hospital Birmingham, Birmingham

Clinical Standards Unit: H.K. Bell (Chairman T&G), L.C. Fuller (Chairman A&CS), N.J. Levell, M.J. Tidman, .D. Yesudian, J. Lear, J. Hughes, A.J. McDonagh, S. Punjabi, N. Morar, S. Wagle (British National Formulary), S.E. Hulley (British Dermatological Nursing Group), K.J. Lyons (BAD Scientific Administrator) and M.F. Mohd Mustapa (BAD Clinical Standards Manager).

Financial Disclosures/Conflicts of Interest

None declared

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Roberts DL, Anstey AV, Barlow RJ, Cox NH, Newton Bishop JA, Corrie PG, Evans J, Gore ME, Hall PN, Kirkham N. U.K. guidelines for the management of cutaneous melanoma. Br J Dermatol 2002 Jan;146(1):7-17. [60 references]

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the British Association of Dermatologists Web site External Web Site Policy.

Availability of Companion Documents

Audit points are provided in the original guideline document External Web Site Policy.

Patient Resources

The following is available:

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI on April 22, 2005. The information was verified by the guideline developer on June 27, 2005. This NGC summary was updated by ECRI Institute on December 23, 2010. The updated information was verified by the guideline developer on February 24, 2011.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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