Synopsis
Explain the sequence from diagnostic melanoma excision to stage-based wide local excision, select sentinel-node discussion using current NICE criteria, and design follow-up around recurrence risk, skin surveillance and patient support.
- Diagnostic excision removes the suspicious lesion completely with a narrow margin to establish melanoma diagnosis, Breslow depth, ulceration and pathological stage.
- Wide local excision is a second procedure around the biopsy scar; its clinical margin is determined by stage and includes the initial primary-lesion margin.
- NICE advises at least 0.5 cm for stage 0, 1 cm for stage I and 2 cm for stage II, using 1 cm if a 2 cm margin would cause unacceptable disfigurement or morbidity.
- Sentinel lymph-node biopsy is a staging procedure for clinically node-negative melanoma; it does not treat the primary lesion and has not itself been shown to improve survival.
- Do not offer imaging or SLNB for stage IA melanoma and do not perform routine imaging before SLNB unless nodal or distant metastasis is suspected.
- Consider SLNB for Breslow 0.8–1.0 mm with ulceration, lymphovascular invasion or mitotic index 2 or more, and for Breslow thickness over 1.0 mm.
- A positive sentinel node changes pathological stage and adjuvant-treatment discussion; routine completion lymph-node dissection is not automatic.
- Follow-up intensity is stage based and includes whole-skin, scar, in-transit and nodal examination, self-examination education, psychosocial support and rapid re-entry for symptoms.
Key red flags
A new scar nodule, in-transit dermal lesion, firm regional node, persistent focal pain, neurological deficit, unexplained weight loss or respiratory symptoms after melanoma requires urgent specialist reassessment rather than waiting for routine follow-up.
A new dermal or subcutaneous nodule between the primary scar and draining nodal basin can represent lymphatic melanoma spread.
A firm enlarging node in the expected basin requires urgent ultrasound and tissue diagnosis rather than observation.
New focal neurology, persistent headache, bone pain, breathlessness or constitutional decline needs stage-aware urgent investigation.
Investigation priorities
Provide Breslow thickness, ulceration, margins and adverse features before definitive planning.
Management branches
A completely sampled primary lesion is confirmed as stage 0, I or II melanoma.
- Review Breslow depth, ulceration, biopsy margins and stage in the specialist skin-cancer multidisciplinary team.
- Plan wide local excision around the histological scar using at least 0.5 cm for stage 0, 1 cm for stage I and 2 cm for stage II unless morbidity dictates the NICE alternative.
- Coordinate reconstruction and verify final margins, preserving function without losing the intended oncological field.