Melanoma

Synopsis

Recognise suspicious pigmented and non-pigmented lesions, obtain a full-thickness diagnostic excision, use Breslow and nodal risk correctly and coordinate wide excision, sentinel staging, adjuvant treatment and advanced immune or targeted therapy.

• Use ABCDE for asymmetry, border, colour, diameter and evolution, plus the ugly-duckling sign; for nodular lesions remember elevated, firm and growing because colour may be absent.
• First-line specialist assessment combines full-skin and regional-node examination with dermoscopy and comparison with photographs where available.
• The diagnostic reference standard for a lesion suspicious for melanoma is full-thickness complete excision with a narrow approximately 2 mm clinical margin and a cuff of subcutaneous fat.
• Avoid superficial shave, curettage, cautery or destructive treatment because they can transect the lesion and prevent accurate Breslow measurement; incisional biopsy is reserved for anatomically difficult large lesions after specialist planning.
• Pathology must report Breslow thickness, ulceration, mitotic and histological features, microsatellites and peripheral and deep margins; Breslow is measured from the granular layer or ulcer base to deepest invasion.
• Definitive wide local excision margin is stage and thickness based: usually 0.5 cm for in-situ disease, 1 cm for stage I and 2 cm for stage II melanoma under NICE guidance.
• Offer sentinel-node biopsy for eligible melanoma over 1 mm and consider it for selected 0.8 to 1 mm lesions with adverse features; it is staging and prognostic, not direct treatment of distant micrometastases.
• Do not perform routine completion lymph-node dissection solely for a positive sentinel node; use nodal-basin ultrasound surveillance and adjuvant-treatment assessment.
• Stage IIB, IIC, III and resected IV disease may qualify for adjuvant anti-PD-1 or BRAF–MEK treatment according to stage, BRAF status and current NICE approval.
• Advanced treatment uses single or combined checkpoint blockade or BRAF–MEK inhibition for a BRAF V600 tumour, selected by tempo, symptoms, brain disease, comorbidity and need for rapid response.
• A rapidly progressive symptomatic BRAF-mutated cancer may respond quickly to targeted therapy, while immunotherapy can produce longer treatment-free control; sequencing is a specialist decision.
• Routine brain and body imaging is stage based rather than used for every thin melanoma; new neurological or systemic symptoms override the surveillance calendar.
• Teach monthly skin and node self-examination, sun protection without vitamin-D neglect and lifelong prompt assessment of changing lesions and treatment toxicity.