What are the next steps in treatment for a patient diagnosed with melanoma after it has been removed?

From the Guidelines

After melanoma removal, the next steps in treatment depend on the stage of the cancer, with regular follow-up skin examinations and potential adjuvant therapy with immunotherapy drugs being crucial for reducing recurrence risk. For early-stage melanomas (Stage 0-I), regular follow-up skin examinations every 3-12 months for 5 years may be all that's needed, as suggested by 1. For Stage II melanomas, sentinel lymph node biopsy might be recommended to check if cancer has spread to nearby lymph nodes. For Stage III or IV melanomas, additional treatments are typically necessary, including immunotherapy (such as pembrolizumab, nivolumab, or ipilimumab), targeted therapy (like dabrafenib plus trametinib for BRAF-mutated melanomas), radiation therapy, or in some cases, additional surgery.

Some key points to consider in the follow-up and treatment of melanoma include:

• Regular self-examinations of the skin and peripheral lymph nodes to detect any relapse or additional skin tumors early, as recommended by 1
• Avoidance of sunburns, extended unprotected solar or artificial UV exposure, and use of sun protection measures such as SPF 30+ sunscreen and protective clothing
• Clinical monitoring to detect relapse and recognize additional skin tumors, especially secondary melanomas, as early as possible
• Potential use of imaging and blood tests, such as serum S100 protein, in the follow-up of melanoma patients, although there is no consensus on the optimal schedule or utility of these tests, as noted by 1

The most recent and highest quality study, 1, provides guidance on the treatment and follow-up of melanoma, including the use of adjuvant therapy with immunotherapy drugs for high-risk melanomas. Adjuvant therapy with immunotherapy drugs is often recommended for 12 months following surgery for high-risk melanomas to reduce recurrence risk. All patients should perform monthly self-skin examinations, use sun protection, and attend regular follow-up appointments with their dermatologist and oncologist. These treatments aim to eliminate any remaining cancer cells and prevent recurrence, as melanoma can potentially spread to other parts of the body if not properly managed.

From the FDA Drug Label

for the adjuvant treatment of adult and pediatric (12 years and older) patients with Stage IIB, IIC, or III melanoma following complete resection. KEYTRUDA may be used: ... in adults and children 12 years of age and older with Stage IIB, Stage IIC, or Stage III melanoma, to help prevent melanoma from coming back after it and lymph nodes that contain cancer have been removed by surgery.

The next steps in treatment for a patient diagnosed with melanoma after it has been removed are:

• Adjuvant treatment with pembrolizumab (KEYTRUDA) to help prevent melanoma from coming back after complete resection, for adult and pediatric patients (12 years and older) with Stage IIB, IIC, or III melanoma 2 2.
• The goal of adjuvant treatment is to reduce the risk of melanoma recurrence.
• Patients should be monitored by their healthcare provider for signs and symptoms of immune system problems and infusion reactions.

From the Research

Next Steps in Treatment for Melanoma

After a patient is diagnosed with melanoma and it has been removed, the next steps in treatment may vary depending on the stage of the tumor and the primary lesion 3. The following are potential next steps in treatment:

• Surgical Excision: The typical therapy for malignant melanoma is surgical excision, which may involve a safety margin of 1 cm in tumors up to 2 mm thick, and 2 cm in thicker tumors 4.
• Sentinel Lymph Node Biopsy: In tumors more than 1 mm thick, sentinel lymph node biopsy should be performed to aid in tumor staging 4.
• Immunotherapy: Adjuvant immunotherapy with interferon alpha is recommended in tumors of thickness >2 mm and in locoregional metastasis 4.
• Targeted Therapy: BRAF inhibitors, such as vemurafenib, may be used to treat metastatic late-stage melanomas harbouring the BRAF-V600 mutation 5, 6, 7.
• Radiotherapy: Radiotherapy is indicated in inoperable tumors of all stages 4.
• Monochemotherapy: If distant metastasis is present and R0 surgery is not an option, the treatment should primarily comprise monochemotherapy or alternatively the patient should be enrolled in a clinical trial 4.
• Pembrolizumab: Pembrolizumab may be used as part of the treatment plan, although previous treatment with BRAF inhibitors may affect the response to pembrolizumab 6.

Factors Affecting Treatment

The treatment plan may be affected by various factors, including:

• Tumor thickness: The thickness of the tumor can affect the treatment plan, with thicker tumors requiring more aggressive treatment 4.
• BRAF mutation: The presence of a BRAF mutation can affect the treatment plan, with BRAF inhibitors being a potential treatment option 5, 6, 7.
• Previous treatment: Previous treatment with BRAF inhibitors may affect the response to subsequent immunotherapy, such as pembrolizumab 6.