return to: Melanoma (Evaluation and Management) (8th Edition AJCC)
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Stage IIC: cT4bN0M0 (AJCC 8th Edition) |
Breslow:
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T4b:
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5 yr survival = 82% (ref Keung 2018) | ||||
|
|
Margins |
Mohs? |
SLN bx |
PET |
CT |
Radiation |
Adjuvant |
|
ESMO |
1 cm |
no |
yes |
no |
no |
no |
|
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NCCN |
2 cm |
no |
yes |
no# |
no# |
no |
no♦ (ref Maio et al. 2018) |
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University of Iowa |
2 cm* |
no** |
yes |
yes |
yes |
consider: PNI, desmoplastic |
no |
*comment: margins are not inviolate and may be modified by proximity to critical structures with attention to lymphatic drainage patterns
**comment: Mohs surgery may be considered for melanoma with lentigo maligna extending beyond the 1 cm margin encompassing melanoma
#comment: Consider nodal basin US prior to SLNB for melanoma patients with equivocal regional lymph node physical exam. Nodal basin US is NOT a substitute for SLNB
♦comment: BRIM8 trail showed that in select patients with resected AJCC 7th Edition stage IIC-III disease and BRAF V600 mutation, adjuvant treatment with the BRAF inhibitor, vemurafenib monotherapy improved disease free survival (DFS) and possibly DMFS compared to placebo. The impact on overall survival (OS) was not statistically significant. Vermuranfenib monotherapy was a/w higher rates of toxicity compared to placebo and is NOT FDA approved for adjuvant treatment of melanoma.
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Follow-up
Modify significantly according to prognosis
- Avoidance of sun exposure
- Surveillance for Stage IIB-IV as per NCCN Guidelines (ref Swetter et al. 2021)
- All melanoma patients: Skin examination and surveillance at least once a year for life is recommended
- H&P:
- every 3-6 months x 2 years then,
- every 3-12 months x 3 years then,
- as clinically indicated
- Routine blood tests are not recommended
- Imaging:
- As indicated to investigate specific signs/symptoms
- Consider every 3-12 months x 2 years then, every 6-12 months x 3 years to screen for recurrence or metastatic disease
- Routine imaging to screen for asymptomatic recurrence or metastatic disease is NOT recommended after 3-5 years, depending on risk of relapse
- All patients with melanoma treated for cure should have at least yearly follow-up with dermatology to permit total-body surveillance.
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References
Swetter, S. M., Thompson, J. A., Albertini, M. R., Barker, C. A., Baumgartner, J., Boland, G., Chmielowski, B., DiMaio, D., Durham, A., Fields, R. C., Fleming, M. D., Galan, A., Gastman, B., Grossmann, K., Guild, S., Holder, A., Johnson, D., Joseph, R. W., Karakousis, G., Kendra, K., Lange, J. R., Lanning, R., Margolin, K., Olszanski, A. J., Ott, P. A., Ross, M. I., Salama, A. K., Sharma, R., Skitzki, J., Sosman, J., Wuthrick, E., McMillian, N. R., & Engh, A. M. (2021). NCCN Guidelines® Insights: Melanoma: Cutaneous, Version 2.2021, Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw, 19(4), 364-376. Retrieved Jun 14, 2021, from https://jnccn.org/view/journals/jnccn/19/4/article-p364.xml
Keung, Emily Z, and Jeffrey E Gershenwald. “The eighth edition American Joint Committee on Cancer (AJCC) melanoma staging system: implications for melanoma treatment and care.” Expert review of anticancer therapy vol. 18,8 (2018): 775-784. doi:10.1080/14737140.2018.1489246
Keilholz U, Ascierto PA, Dummer R, Robert C, Lorigan P, van Akkooi A, Arance A, Blank CU, Chiarion Sileni V, Donia M, Faries MB, Gaudy-Marqueste C, Gogas H, Grob JJ, Guckenberger M, Haanen J, Hayes AJ, Hoeller C, Lebbé C, Lugowska I, Mandalà M, Márquez-Rodas I, Nathan P, Neyns B, Olofsson Bagge R, Puig S, Rutkowski P, Schilling B, Sondak VK, Tawbi H, Testori A, Michielin O. ESMO consensus conference recommendations on the management of metastatic melanoma: under the auspices of the ESMO Guidelines Committee. Ann Oncol. 2020 Nov;31(11):1435-1448. doi: 10.1016/j.annonc.2020.07.004. Epub 2020 Aug 4. PMID: 32763453.
Maio M, Lewis K, Demidov L, et al. Adjuvant vemurafenib in resected BRAF(V600) mutation-positive melanoma (BRIM8): a randomized, double-blind, placebo-controlled, multicentere, phase 3 trial. Lancet Oncol 2018; 19:510-520.