Cutaneous melanoma — diagnostic and therapeutic guidelines in 2013

Abstract

The classic criteria for clinical diagnosis of cutaneous melanoma are:  asymmetry of the lesion, irregularity of the boarder,  color heterogeneity and diameter of more than 5 mm. Current data show that over 50% of melanomas do not fulfill these criteria. Thus, dermoscopy is currently the standard method for clinical differential diagnosis of cutaneous melanoma and for qualifying a lesion for excisional biopsy. Full thickness excisional biopsy of suspicious melanomatous skin lesions likely to be diagnosed as early melanomas is crucial in establishing diagnosis and defining prognostic factors. Early diagnosis and surgical removal of cutaneous melanoma not only improves patients’ prognosis, but it is also associated with approximately 90% likelihood of cure. Next steps in the therapeutic management of cutaneous melanoma following excisional biopsy are radical scar excision with adequate margins and sentinel lymph node biopsy. Radical lymph node dissection is recommended in case of regional lymph node metastases. High-risk patients (lymph node involvement and/or ulcerated primary lesion) should be advised to participate in prospective clinical trials on adjuvant therapy. Melanoma patients with distant metastases are still characterized by poor outcomes. In patients with metastatic disease testing for the presence of BRAF gene mutation is recommended.  Patients with metastatic disease should be considered for participation in clinical trials. Long-term survival is confined to selected group of patients undergoing resection of isolated metastatic lesions. In systemic – mainly first-line – therapy of patients with BRAF V600 mutation vemurafenib (BRAF inhibitor) may be employed and in second-line treatment – based on indication approved in Europe – ipilimumab (anti-CTLA4 antibody) may be used. Dacarbazine-based chemotherapy is less effective.