For a woman with a primary cutaneous melanoma on the back excised with clear margins, what additional skin, lymph‑node, imaging, and gynecologic examinations are indicated?

Post-Melanoma Surveillance for Women with Clear Margins

For a woman with a completely excised primary cutaneous melanoma on the back with clear margins, perform a complete skin examination (including scalp) and regional lymph node palpation; routine gynecologic referral is NOT indicated unless there are specific gynecologic symptoms or findings. 1, 2

Required Clinical Examinations

Comprehensive Skin Assessment

• Examine the entire skin surface, including the scalp, to detect second primary melanomas or metastatic lesions 1, 2
• This is a standard recommendation for all patients with isolated primary melanoma 1
• Patients with one melanoma have increased risk of developing additional primary melanomas, making full-body skin examination essential 2

Regional Lymph Node Evaluation

• Palpate all regional lymph nodes (for a back melanoma, this includes axillary and potentially cervical nodes depending on exact location) 1, 2
• Regional lymph node enlargement is highly suggestive of nodal metastasis, with risk correlating to tumor thickness and invasion level 2, 3
• The number of involved lymph nodes is the most important prognostic factor if nodal disease develops 2, 3

When Additional Imaging is NOT Needed

For isolated primary melanoma with no clinically detectable nodes and clear margins, there is no need for further investigations 1

This guideline applies when:

• Margins are histologically clear
• No palpable lymphadenopathy is present
• No clinical signs of metastatic disease exist

Optional Lymph Node Imaging

• Ultrasound of superficial regional nodes is indicated only for cases of clinical uncertainty (e.g., equivocal palpation findings) 1, 2
• This is not routine for all patients 1

Gynecologic Examination: When to Refer

NOT Routinely Indicated

There is no standard indication for gynecologic referral solely based on a diagnosis of cutaneous melanoma on the back 1, 2

The guidelines for isolated primary cutaneous melanoma focus exclusively on:

• Skin examination
• Regional lymph node assessment
• No mention of routine gynecologic screening beyond standard age-appropriate care

When Gynecologic Referral IS Appropriate

You would send a patient to gynecology if:

• Symptomatic concerns arise such as postmenopausal bleeding, vulvar lesions, or vaginal discharge 4, 5
• Pigmented lesions are noted on the vulva or vagina during examination, as primary melanomas of the female genital tract are rare but aggressive 4, 5, 6
• Regional nodal involvement is detected and you need to rule out distant metastases in pelvic organs (though this would typically involve imaging first) 1

Important Context on Genital Melanomas

• Primary melanomas of the female genital tract (vulva, vagina, cervix) are extremely rare, comprising <2% of melanomas in women 4, 6
• These have different etiology than cutaneous melanoma and are not related to having a back melanoma 6
• They present with gynecologic symptoms (bleeding, visible lesions) rather than being detected through screening 4, 5
• Elderly women should undergo regular gynecologic examinations for age-appropriate screening, and suspicious pigmented genital lesions should be biopsied 4

Staging-Dependent Surveillance

For Clinically Node-Negative Disease

• No routine imaging (CT, MRI, PET) is indicated 1
• Sentinel lymph node biopsy may be considered based on tumor thickness (≥0.8 mm or ulcerated lesions), but this is a surgical staging procedure, not routine imaging 1, 7

If Regional Nodes Become Involved

• Search for distant metastases becomes justified to guide therapy 1, 2
• Approximately 10% of patients with nodal involvement have asymptomatic distant metastases at diagnosis 1, 2, 3
• Abdominal, thoracic, and cerebral CT scans are most useful for detecting distant disease 1, 2

Common Pitfalls to Avoid

• Do not order routine imaging (CT, PET, MRI) for stage I-IIA melanoma with clear margins and no palpable nodes—this increases cost and false-positive findings without survival benefit 1
• Do not refer to gynecology unless there are specific gynecologic symptoms or findings—cutaneous melanoma does not increase risk of genital tract melanoma 4, 6
• Do not skip full-body skin examination—missing a second primary melanoma is a preventable error 1, 2
• Do not forget to document tumor thickness (Breslow depth), ulceration, and Clark level from pathology, as these determine surveillance intensity and adjuvant therapy eligibility 1, 7