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MELANOMA SURVEILLANCE
Protocols for the longitudinal care of melanoma patients vary worldwide and generally depend on the risk of disease recurrence and development of new primary melanomas. Lifelong follow-up of these patients is important because of: (1) the risk of second primary cutaneous melanomas (3.5%โ4.5%, depending on nevus phenotype and/or genetic factors); (2) the risk of local and/or metastatic recurrence (greatest in
the first 2โ5 years after initial diagnosis and stage-dependent); (3) the risk of late recurrence (>10โ15 years) which is uncommon but does occur; and (4) the increased risk of other cutaneous malignancies (e.g. cutaneous SCC, BCC).
Most stage I/II cutaneous melanomas will present with locoregional recurrence, while stage III/IV patients most often present with systemic metastases. The latter group is typically followed by an oncologist, although ongoing dermatologic assessment is important for detection of disease recurrence and new primary melanomas, as well as recognition and treatment of cutaneous side effects from targeted and immune therapies. Recommendations for the frequency of dermatologic visits varies internationally and amongst practitioners. As 90% of recurrences occur during the first 5 years following primary diagnosis (with the greatest risk in the first 2 years), most experts recommend dermatologic visits one to four times per year for 2 years after diagnosis (depending on risk of disease recurrence and alternating with oncologic visits in those with higher stage disease), then every 6 to 12 months through year 5 following diagnosis, then at least annually thereafter. Clinical surveillance frequency is also influenced by the number of melanocytic nevi (common and atypical), number of primary cutaneous melanomas, and genetic susceptibility, which increases the risk of additional primary melanomas.
Dermatologic visits should include: (1) updates on the medical history; (2) review of systems (e.g. any new or changing lesions, new โlumps or bumpsโ in or around the melanoma excision site or in nodal basins, unanticipated weight loss, fatigue, headache or other CNS symptoms, shortness of breath); (3) total body skin examination; (4) examination and palpation of the melanoma scar/excision site and surrounding area for local recurrences or in-transit metastases; (5) examination of regional and distant lymph nodes; and (6) laboratory and radiologic tests as indicated by concerning signs and/or symptoms. Patients should be counseled to adhere to sun-protective measures; perform skin self-examinations at home; and to take an oral vitamin D supplement, particularly if they are practicing regular sun protection. Family members should also be encouraged to undergo routine skin examinations.
While early detection of asymptomatic melanoma metastasis has not been clearly associated with improved survival, most data pertain to the era of minimally effective systemic therapies. The future of melanoma diagnosis and treatment will likely involve molecular techniques that accurately demonstrate residual disease (e.g. ctDNA) or have proven validity for prognosis and staging to determine which patients require SLNB, surveillance imaging, and/or adjuvant therapy following resection of the primary tumor.
The merits of early detection of primary melanoma cannot be under-stated. Diagnosis of melanoma when thin and most curable will reduce patient morbidity and associated costs of care. Primary prevention aimed at avoiding natural and artificial sources of UVR, and early detection strategies for this visible and largely recognizable cutaneous tumor should be at the forefront of public health measures.
Additional figures and table on Invasive cutaneous melanoma - components of the histopathologic report, available in our eBook (see inside front cover for access code).