As for follow-up of patients with newly diagnosed cutaneous melanoma, the guidelines recommend an annual visit with a dermatologist at the least, but note that visits may range from every 3-12 months based on a patient’s history and risk factors. "The goal of follow-up is to detect any evidence of local recurrence and to detect any additional primary melanomas that may have developed," Dr. Kent said. "I have several patients that have personally had over three melanomas. One patient has had five. Some high risk patients we see every 3 or 4 months for follow-up."
Sentinel Lymph Node Biopsy and Lentigo Maligna
The work group also addressed non-surgical treatments for lentigo maligna, a topic that was not contained in the older version of the guidelines. For example, while off-label use of topical imiquimod has been proposed for lentigo maligna, "studies are limited by highly variable treatment regimens and lack of long-term follow-up with an average of approximately 18 months," the work group wrote. "Histologic verification following treatment has shown persistent disease in approximately 25% of treated patients and progression to invasive melanoma has been noted. As an adjunctive modality following surgical excision, the efficacy of topical imiquimod has not been established. High cost of treatment, an appropriate low threshold for subsequent biopsy to exclude residual or recurrent disease, and the risk of a severe inflammatory reaction should be taken into account when considering imiquimod."
SLNB is another topic contained in the guidelines for the first time. While the work group acknowledged that SLNB is "not without controversy," it described sentinel lymph node status as "the most important prognostic factor for disease-specific survival of patients with melanoma greater than 1 mm in thickness. Whether early detection of occult nodal disease provides greater regional control has not been definitively shown, but available evidence suggests a lower rate of post-operative complications in patients who underwent completion lymph node dissection for micrometastatic disease detected by SLNB, compared to those who underwent therapeutic lymph node dissection for clinically palpable disease."
The work group acknowledged that "significant gaps" exist in research related to the management of primary cutaneous melanoma, including "standardization of the interpretation of mitotic rate; placebo-controlled trials for the treatment of lentigo maligna; the use and value of dermoscopy and other imaging modalities; the clinical and prognostic significance of the use of biomarkers and mutational analysis; and the use of sentinel lymph node biopsy."
For his part, Dr. Kent predicted that major advances in the treatment of cutaneous melanoma should occur in the coming years. "Melanoma is a very unpredictable disease," he said. "Hopefully sometime in the future, we’ll have biomarkers that will assist physicians in identifying patients who are a greater risk of more aggressive disease, of spread to both regional and distant sites. That area of research is very exciting."
Dr. Kent said that he had no relevant financial disclosures.