Management of Cutaneous Melanoma

Melanoma is the fifth most common cancer in the United States and one of the deadliest. Tumor depth (Breslow depth) is the most important prognostic factor. Wide local excision is used to manage melanoma stage 0 (in situ) with 0.5- to 1-cm margins, as well as stage IA with 1-cm margins. For lentigo maligna (melanoma in situ), surgical margins wider than 0.5 cm are often necessary to achieve histologically negative margins, and comprehensive margin assessment techniques (Mohs surgery or staged excision) are associated with lower recurrence rates. Localized melanoma with a Breslow depth of less than 0.8 mm and without ulceration has an excellent prognosis and low risk for metastasis; standard treatment is wide local excision with 1-cm margins. Referral is required for melanoma stage IB or higher for discussion of sentinel lymph node biopsy and consideration of adjuvant therapies. Advances in sequencing have enabled tailored therapies for metastatic melanoma based on variations in somatic genes. Immunotherapy has improved survival in those with advanced melanoma. Genetic counseling should be considered for patients with a personal or family history of melanoma or certain other cancers (notably pancreatic cancer, uveal melanoma, mesothelioma, or astrocytoma). After a melanoma diagnosis, patients should undergo full skin examinations at least annually for surveillance.