What are the prevention, detection, and treatment options for melanoma?

Melanoma Prevention, Detection, and Treatment

The best prevention for melanoma is physical protection from ultraviolet (UV) radiation with appropriate clothing and regular sunscreen use, while early detection through regular skin examinations using the ABCD rule and dermoscopy by experienced physicians significantly improves survival outcomes. 1

Prevention Strategies

Primary Prevention

• UV Protection: UV radiation is a major carcinogen in melanoma development 1
  • Physical protection with appropriate clothing is most effective 1
  • Regular sunscreen use has been shown to reduce primary cutaneous melanoma incidence in randomized trials 1
  • Avoid sun exposure during peak hours (10 a.m. to 4 p.m.) 2
  • Wear hats and UV-opaque sunglasses 3
  • Seek shade when outdoors 2

High-Risk Groups Requiring Special Attention

• Fair-skinned individuals (Fitzpatrick skin types I and II) 4
• People with multiple atypical nevi 1
• Personal or family history of melanoma 4
• Individuals with history of excessive UV exposure 5
• Young adult women (higher sunbed use) 5
• Elderly men (for secondary prevention) 5

Detection Methods

Clinical Examination

• ABCD Rule for suspicious lesions 1:

  • Asymmetry
  • Border irregularities
  • Color heterogeneity
  • Dynamics (evolution in colors, elevation, or size)

• "Ugly Duckling" Concept: Identifying lesions that don't match the individual's typical nevus pattern 1

• Enhanced Detection Methods:

  • Dermoscopy by experienced physicians significantly improves diagnostic accuracy (Level II, B evidence) 1
  • Automated video-dermoscopy systems for patients with multiple atypical nevi 1
  • Full-body imaging with high-resolution pictures 1

Diagnostic Procedures

• Biopsy: Full-thickness excisional biopsy with minimal side margin is the standard 1

  • Alternatives: deep scoop shave, saucerization, or punch biopsy ensuring complete lesion removal 4
  • Processing by experienced pathology institute is mandatory 1

• Histology Report Requirements:

  • Maximum thickness in millimeters (Breslow depth) 1
  • Presence of ulceration 1
  • Mitotic rate (especially for tumors <1mm) 1
  • Surgical margin clearance 1
  • Presence and extent of regression 1
  • Anatomical site information 1
  • Melanoma type (superficial spreading, lentigo maligna, acral lentiginous, nodular) 1

Treatment Approaches

Surgical Management

• Wide local excision is the primary treatment of choice 4
  • Margin width depends on Breslow depth 4
  • Thin lesions (<0.8mm) typically need no further treatment after wide excision 4

Advanced Disease Management

• Staging Procedures for lesions >0.8mm may include:

  • Sentinel lymph node biopsy 4
  • Complete lymph node dissection when indicated 4
  • Mutation analysis for BRAF, NRAS, and c-Kit in metastatic disease 1

• Systemic Therapy for advanced melanoma:

  • Immunotherapy (including checkpoint inhibitors like nivolumab) 6, 4
  • Targeted therapy (BRAF/MEK inhibitors for BRAF-mutated melanoma) 2

Follow-up Recommendations

Surveillance Schedule

• Stage 0 (in situ): Skin examination at least annually for life 7
• Stage IA-IIA:
  • Skin examination every 3-12 months for 5 years
  • Annually thereafter 1, 7
• Stage IIB-IV:
  • Skin examination every 3-6 months for 2 years
  • Every 3-12 months for years 3-5
  • Annually thereafter 1, 7

Patient Education

• Monthly self-examination of skin and lymph nodes 1, 7
• Lifelong dermatologic surveillance is justified as:
  • Most recurrences occur within 5 years 1
  • Late recurrence (≥10 years) is well documented 7
  • Lifetime risk of second primary melanoma is 4-8% 1, 7

Prognosis

• Overall 5-year survival rate has improved to 93.3% in the US 2
• Advanced disease (Stage IV) survival remains at approximately 30% 2
• Immunotherapy has significantly improved survival for advanced melanoma, with 5-year survival rates increasing from 16% to 35% for stage IV disease 4

Common Pitfalls to Avoid

• Relying on sunscreen alone without other protective measures 3
• Using sunscreen to prolong intentional sun exposure 5
• Neglecting regular skin self-examinations 5
• Overlooking small melanomas (<5mm) which are increasingly common 1
• Delaying biopsy of suspicious lesions 4
• Inadequate biopsy technique preventing accurate Breslow depth measurement 4
• Neglecting lifelong surveillance due to risk of late recurrence and second primaries 1, 7