Updated Melanoma Treatment Guidelines

I’ve had this tab open on my browser for some time, waiting for the day that my headache would subside enough for me to write. But seeing as I will likely have a permanent headache for the foreseeable future (and yes, I did go to a doctor and they told me basically that it was all in my head – har, har), I might as well write this post now.

The American Academy of Dermatology clinical guidelines on the management of primary cutaneous melanoma were last updated in 2011. For an old lady like me, 2011 seems like last week; but in reality, it’s eight years ago (half of today’s pop music I bitch about is made by people who were in elementary school eight years ago… heck, the majority of the Kardashians probably had their original lips and noses back then). And the world of science has advanced quite rapidly in those eight years.

The new guidelines incorporate recommendations from the American Joint Committee on Cancer (AJCC) on a variety of topics, including: staging definitions, biopsy and sentinel lymph node biopsy, pathology, and primary surgery.

Let’s first talk about biopsies as that is the procedure that takes all or a portion of the suspected lesion for lab testing. Obviously I had a biopsy performed that introduced me to the wonderful world of melanoma (I so wish we had a sarcasm font, that would make my life so much easier). The biopsy (actually the lab results from the biopsy, but whatever) allows a physician to definitely diagnose melanoma. It also determines the thickness of the lesion, which is an important consideration for staging (which I’ll talk about in a minute).

The new recommendations call for a complete biopsy of the lesion with up to 3mm margins around the entire spot. It also states that the biopsy should be deep enough to get underneath the base of the lesion. For my Loki, following these guidelines would have basically meant I would have had the excision at the same time as the biopsy. Which would have resulted in a considerable scar “just to see”. Fortunately, the guidelines do allow for partial or incomplete sampling based on the location. For nodular melanomas that grow in thickness or depth, a dermatologist may opt for a partial biopsy rather than digging deep into your tissues to make a diagnosis. But for those of you with superficial spreading melanoma (SSM), your biopsies may include a slightly bigger bullet hole in the future.

Ok, so that leads us to staging. As you probably know, cancer is broken into categories called stages (actually lots of medical conditions are broken out into stages). The stage of melanoma you are diagnosed with greatly impacts your plan of action. Using the TNM Staging model, stages can define the tumor (cleverly using a T + a number between 1 and 4 to describe, plus a letter), whether the lymph nodes are involved (which is signified by an N + a number between 1 and 4 plus some more letters), and whether the cancer has metastasized (options are M1 which can also have letters and M0 which doesn’t get letters). The diagnosis you get could be something like this: T3a / N1b / M1a. (In a post in the not-too-distant future I’m going to break down further what all of that means. I was going to address here but I think it warrants its own post.)

Anyway, in the new guidelines Stages 1 and 2 got the most updates, specifically regarding that tumor element. A T1 melanoma was defined as being a lesion that has a thickness less than 1 mm. Under the new guidelines, if you have a lesion that isn’t ulcerated and has a thickness less than 0.8 mm, you would be diagnosed with T1a. (By the way, ulcerated means, does the tumor have broken skin over the top of it and make it scabby or even bloody looking? The “a” and “b” in the diagnosis here denotes that.)

A T1b diagnosis would now mean any lesion, ulcerated or not, with a thickness between 0.8 and 1.0 mm OR an ulcerated lesion less than 0.8 mm thickness. So instead of the “a” and “b” signaling only ulceration in these thinner lesions, it would really mean thickness with or without ulceration.

For all other melanoma T stages, the classification would follow the standard “a” for no ulceration and “b” for ulceration. T2 would be classified if the thickness is greater than 1.0 up to 2.0 mm; T3 greater than 2.0 up to 4.0 mm; and T4 for any lesion with a thickness greater than 4.0 mm.

For someone used to the standard classification system, the only quibble I have is with the T1 staging because of the changes to the “a” and “b” designations for only that stage. I know it would probably cause even more confusion to add something else to the Ts (like T0.5 for those smaller than 0.8 mm with no ulceration), but still… There were no updates recommended for the N or M letters.

OK, onto pathology… these recommendations actually surprised me because in my naïveté, I assumed that these were standard operating procedures… anyway, it is now recommended that the pathologist looking at the biopsied tissue be given information about the patient – things like age, gender, location of the lesion, whether there is a previous history of melanoma, whether the lesion had changed, and such. I get not wanting to taint the pathologist’s independent opinion but I would have thought that the patient’s chart or something would be available to the pathologist anyway. Working in a vacuum without any of that information would make it more difficult to decide if something should get a bit more attention, don’t you think?

And finally, the surgical recommendations… obviously, surgery or excision is recommended after biopsy to ensure complete removal of the melanoma cells. You know that lovely phrase “the margins are clear”? That basically means that they looked at the patch of hopefully normal skin around the entire lesion and didn’t find melanoma cells. The new recommendations are concerned with those margins. So the greater in thickness your lesion, the bigger the margins should be. If you have a 1mm tumor, the recommended margin would be 1 cm (and yes, I meant to type 1 cm). Basically, up to 2 cm of margin (i.e. clear skin around the lesion) should be taken during surgery or excision to remove the tumor. The minimum recommendation is 0.5 cm, but that’s only for melanoma in situ, which is only in the very top layer of skin. Oh, and the margins should be measured by the surgeon from the lesion or biopsy site, not from whatever was in the pathology report.

Ok, those are margins, but how deep will the excision or surgery go? The new recommended depth of excision is all the way to (but not including) the fascia, so basically pretty f’ing deep depending on the location of the tumor. (My excision went through the fascia as well because my Loki was a jerk and picked my knee to homestead.)

They also recommend that if you have to undergo a sentinel lymph node biopsy, that it should be done before the excision but at the same time as the procedure. So, sort of a 2-for-1 for the patient. Which makes sense that if you think your patient needs lymph nodes checked too, just do it all at once so the patient isn’t wasting time on getting the information needed to know the best course of treatment. I say it all the time here, but the earlier you catch and treat melanoma, the better the survival odds.

So when should someone need to think about sentinel lymph node biopsies? If you have melanoma in situ or an unulcerated lesion with a depth less than 0.8 mm, you don’t need it and the doctor wouldn’t recommend it. Anything greater than a T1a, then it’s kinda up to the doctor to discuss it with you and decide whether it makes sense. And if you have a T1a but are cutting it close to that 0.8 mm depth and have some other high-risk factors, you might have your doctor recommend it. From the sounds of it, a lot more melanoma patients might be at least discussing sentinel lymph node biopsies with their doctors in the future.

There are other topics covered in the new guidelines but these are the ones that will have the most impact for the majority of melanoma patients.