What is the recommended course of action for a suspected melanoma?

Management of Suspected Melanoma

For any lesion suspicious of melanoma, urgent referral to a dermatologist or surgeon with expertise in pigmented lesions is essential, followed by complete excisional biopsy with 2-5mm margins and a cuff of subdermal fat for definitive diagnosis. 1

Initial Assessment and Referral

• Patients with lesions suspicious of melanoma should be referred urgently to a dermatologist or surgeon/plastic surgeon with expertise in pigmented lesions 1, 2
• Specialists should ensure systems are in place to see patients with suspicious lesions within 2 weeks of referral 1, 2
• All patients who had lesions removed by general practitioners that are subsequently reported as melanoma should be immediately referred to specialists 1

Diagnostic Approach

Clinical Examination

• Any patient with a suspicious pigmented lesion should undergo a full skin examination 1, 2
• Document site and size of the pigmented lesion and record other pigmented lesions 1
• Clinical photographs are helpful for documentation 1, 2
• Examine for lymphadenopathy and hepatomegaly 1, 2

Biopsy Technique

• Preferred approach: Complete excisional biopsy with 1-3mm margins that include the entire breadth of the lesion and sufficient depth to prevent transection at the base 1
• This may be accomplished by fusiform/elliptical excision, punch excision, or deep shave/saucerization to a depth below the anticipated plane of the lesion 1
• The biopsy should include a cuff of subdermal fat to allow accurate staging 1
• Shave and punch biopsies are not recommended as primary diagnostic procedures as they make pathological staging impossible 1
• Incisional biopsy is only acceptable in select circumstances (facial lentigo maligna, acral melanoma, very large lesions) and should only be performed by specialists 1

Management Based on Diagnosis

Surgical Management

• After diagnosis, surgical excision with appropriate margins based on Breslow thickness is required 1, 3:
  • In situ: 5mm margins to achieve complete histological excision 1
  • <1mm thickness: 1cm margins 1, 2
  • 1.01-2mm thickness: 1-2cm margins 1, 2
  • 2.1-4mm thickness: 2-3cm margins 1, 2

  • 4mm thickness: 3cm margins 1

Additional Treatments

• For stage IIB-C melanoma, adjuvant anti-PD-1 immunotherapy (nivolumab or pembrolizumab) improves recurrence-free survival 3
• For stage III disease, anti-PD-1 immunotherapy or BRAF + MEK inhibitor therapy decreases recurrence risk 3
• For metastatic or unresectable melanoma, dual checkpoint blockade with ipilimumab and nivolumab is first-line therapy 3

Follow-up Recommendations

• Patients with in situ melanomas do not require follow-up 1
• Patients with stage IA melanoma should be seen 2-4 times over 12 months, then discharged 1
• Patients with stage IB-IIIA melanoma should be seen every 3 months for 3 years, then every 6 months to 5 years 1
• Patients with stage IIIB, IIIC, and resected stage IV melanoma should be seen every 3 months for 3 years, every 6 months to 5 years, then annually to 10 years 1
• Patients with unresectable stage IV melanoma are seen according to need 1

Surveillance of High-Risk Individuals

• Patients at moderately increased risk (previous melanoma, atypical mole syndrome, organ transplant recipients) should be taught self-examination 1
• Patients with giant congenital pigmented nevi require long-term follow-up 1
• Individuals with a family history of three or more melanoma cases should be referred for genetic counseling 1

Common Pitfalls to Avoid

• Delaying referral for suspicious lesions 1
• Using shave or punch biopsies as primary diagnostic procedures for suspected melanoma 1
• Performing incisional biopsies in primary care settings 2
• Prophylactic excision of pigmented lesions without suspicious features 1, 2
• Partial removal of melanocytic lesions, which can result in pseudomelanoma and diagnostic confusion 1, 2
• Underestimating the extent of lentigo maligna, particularly on the face 2