Logo for University of Iowa Health Care This logo represents the University of Iowa Health Care
Septoplasty For Nasal Obstruction Indications and TechniquesClick Here
Make a Donation

Stage IIIA: cT1a-T2a; N1a/N2a; M0

last modified on: Thu, 04/18/2024 - 16:47

return to: Melanoma (Evaluation and Management) (8th Edition AJCC)

Stage IIIA:

  • cT1aN1aM0
  • cT1aN2aM0
  • cT1bN1aM0
  • cT1bN2aM0
  • cT2aN1aM0
  • cT2aN2aM0

5-yr survival: 93% (ref Keung et al. 2018)

N1: 1 tumor-involved node or transit, satellite and/or microsatellite metastases with no tumor-involved nodes

  • N1a: 1 clinically occult (detected by SLNB)

N2: 2 or 3 tumor-involved nodes or in-transit, satellite, and/or microsatellite metastases with 1 tumor-involved node

  • N2a: 2 or 3 clinically occult (detected by SLNB)

 

Margins

Mohs?

SLN bx

PET

CT

Radiation

Adjuvant

ESMO

1 cm

no

yes

yes

yes

no

consider but not routine use#

NCCN

per T

no

yes§

yes

yes

consideration is appropriate

yes♦

University of Iowa

per T*

no**

yes

yes

yes

yes***

yes

*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

***may consider holding irradiation if nodal burden is small and w/o ECS

#comment: there may be some subsets of stage IIIA patients with higher risk of relapse (tumor burder in sentinel node >1mm). In these patients, discussion of risk reduction and long-term side-effects of adjuvant therapy can be considered.

§comment: sentinel node positive, consider imaging for baseline staging, nodal basin US surveillence (preferred) or completion lymph node dissection (CLND)

♦comment: consider BRAF mutation testing. Options for systemic therapy:

  • Preferred regimens (ref. Swetter et al.)
    • nivolumab
    • pembrolizumab
    • dabrafebib/trametinib for patients with BRAF V600-activating mutation
  • Observation

________

Follow-up

  1. Avoidance of sun exposure

  2. Surveillance for Stage IIB-IV as per NCCN Guidelines (ref Swetter et al. 2021)

    1. All melanoma patients: Skin examination and surveillance at least once a year for life is recommended

    2. H&P:

      1. every 3-6 months x 2 years then,

      2. every 3-12 months x 3 years then,

      3. as clinically indicated

    3. Routine blood tests are not recommended

    4. Imaging:

      1. As indicated to investigate specific signs/symptoms

      2. Consider every 3-12 months x 2 years then, every 6-12 months x 3 years to screen for recurrence or metastatic disease

      3. Routine imaging to screen for asymptomatic recurrence or metastatic disease is NOT recommended after 3-5 years, depending on risk of relapse

      4. All patients with melanoma treated for cure should have at least yearly follow-up with dermatology to permit total-body surveillance.

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.