Malignes Melanom S3‐Leitlinie “Diagnostik, Therapie und Nachsorge des Melanoms”

Abstract

This first German evidence-based guideline for cutaneous melanoma was developed under the auspices of the German Dermatological Society (DDG) and the Dermatologic Cooperative Oncology Group (DeCOG) and funded by the German Guideline Program in Oncology. The recommendations are based on a systematic literature search, and on the consensus of 32 medical societies, working groups and patient representatives. This guideline contains recommendations concerning diagnosis, therapy and follow-up of melanoma. The diagnosis of primary melanoma based on clinical features and dermoscopic criteria. It is confirmed by histopathologic examination after complete excision with a small margin. For the staging of melanoma, the AJCC classification of 2009 is used. The definitive excision margins are 0.5 cm for in situ melanomas, 1 cm for melanomas with up to 2 mm tumor thickness and 2 cm for thicker melanomas, they are reached in a secondary excision. From 1 mm tumor thickness, sentinel lymph node biopsy is recommended. For stages II and III, adjuvant therapy with interferon-alpha should be considered after careful analysis of the benefits and possible risks. In the stage of locoregional metastasis surgical treatment with complete lymphadenectomy is the treatment of choice. In the presence of distant metastasis mutational screening should be performed for BRAF mutation, and eventually for CKIT and NRAS mutations. In the presence of mutations in case of inoperable metastases targeted therapies should be applied. Furthermore, in addition to standard chemotherapies, new immunotherapies such as the CTLA-4 antibody ipilimumab are available. Regular follow-up examinations are recommended for a period of 10 years, with an intensified schedule for the first three years.

Follow-up in melanoma patients

“…Of note, the 5-year recurrence free survival in IIIA, IIIB, IIIC stages (according to American Joint Committee on Cancer—AJCC) is equal to 50–63 %, 26–32 % and 11–12 % as compared with 5-year recurrence free survival in stages IA, IB, and IIA equal to 95 %, 82 %, 72 %, respectively [2, 6, 13, 15, 16]. Because the recurrence rate is the highest in the first 2–3 years after treatment, follow-up visits must be intensified in this period [17, 18]. …”

“…The main goal of the follow-up is to detect a locoregional relapse possible to be treated surgically [1, 9, 12, 13, 16, 17, 19, 20]. The most common site of the first relapse is local relapse or in-transit metastases (20–28 % of patients), more than 25 % of patients have regional lymph node involvement and 15–50 % of cases present distant metastases.…”

“…However, during follow-up in stage III patients the asymptomatic relapse can be revealed with CT scans in 72 % [16], which justifies the recommendation of using chest and abdomen CT imaging for early detection of disease recurrence in this group of patients [17]. In this group of patients (with exception of IIIC stage), the role of the brain CT or magnetic resonance imaging (MRI) is not clear, especially taking into account the cost-effectiveness ratio.…”

“…In stage IIIC melanoma patients Romano et al found the risk of recurrence in the form of brain metastases in more than 5 % during the first 13 months after locoregional therapy; this may justify performing control MRI in this subset of patients [16]. MRI has been proven to be more sensitive and specific in the detection of cerebral metastases than CT or PET-CT [17]. Nowadays, increasing number of guidelines suggest that in stages IIC–IIIC, abdominal and chest radiological imaging (e.g., CT or MRI scan) should be recommended in asymptomatic patients during the first 2–3 years due to higher risk of relapse and for earlier qualifying low-tumor burden patients with disease dissemination to systemic therapy with new effective drugs (BRAF/MEK inhibitors or immunotherapy) [6, 17, 32].…”

“…MRI has been proven to be more sensitive and specific in the detection of cerebral metastases than CT or PET-CT [17]. Nowadays, increasing number of guidelines suggest that in stages IIC–IIIC, abdominal and chest radiological imaging (e.g., CT or MRI scan) should be recommended in asymptomatic patients during the first 2–3 years due to higher risk of relapse and for earlier qualifying low-tumor burden patients with disease dissemination to systemic therapy with new effective drugs (BRAF/MEK inhibitors or immunotherapy) [6, 17, 32]. Before the era of BRAF/MEK inhibitors, the intensive radiological tests following earlier treatment have shown limited benefit of survival (about 2 months of increasing of median survival) [6, 17].…”