Metastatic Workup for Melanoma

Melanoma skin cancer ---> metastatic melanoma ---> diagnosis of melanoma

In an attempt to standardize staging workup for melanoma, the National Comprehensive Cancer Network (NCCN) has published guidelines. There are three basic reasons to perform a metastatic workup following the diagnosis of primary cutaneous melanoma: (a) for staging and prognosis, (b) to detect an early metastasis with potential survival benefit, and (c) to avoid morbidity of an extensive surgical procedure by detection of a distant metastasis. The best test for the staging workup still starts with a history (focused review of systems concentrating on constitutional, respiratory, neurologic, hepatic, musculoskeletal, gastrointestinal, skin, and lymphatic systems) and physical examination (total body skin examination, palpation of lymph nodes). Routine imaging and blood studies in asymptomatic patients are low in both sensitivity and specificity. False-positive staging tests are common and lead to more tests and patient distress. SLNB represents the best baseline staging test, with both relatively high sensitivity and specificity in patients at significant risk for metastasis. The ability to detect stage IV disease with routine studies is small if the SLNB is negative. Ultrasound is perhaps the most sensitive noninvasive test to detect small nodal metastases. However, the sensitivity and specificity of ultrasound and PET scanning are inferior to tissue diagnosis with SLNB.

Evaluation for Metastatic Melanoma

Melanoma skin cancer ---> metastatic melanoma ---> diagnosis of melanoma

The follow-up evaluation for patients with AJCC stage I, II, or III melanoma who are rendered tumor free by surgery should include regular histories and physical examinations. The use of extensive and frequent radiographic studies and blood work in asymptomatic, clinically disease-free patients is rarely productive. In 2004, the National Comprehensive Cancer Network issued guidelines for follow-up of patients with various stages of disease. For AJCC stage IA, patients should undergo a history and physical examination with emphasis on skin and nodal examinations every 3 to 12 months as clinically indicated. For AJCC stage IB to III, patients should undergo a history and physical examination every 3 to 6 months for 3 years, then every 4 to 12 months for 2 years, then annually as clinically indicated. The use of chest radiographs and blood work, and other imaging scans are indicated when clinically indicated, is based on the history and physical examination.
Melanoma can disseminate to any organ. The most common sites of recurrence are skin, subcutaneous tissues, and distant lymph nodes, followed by visceral sites. Common visceral sites of metastasis, in order of decreasing occurrence, are lung, liver, brain, bone, and gastrointestinal tract. Most patients who die with disseminated disease have multiple organ involvement. Frequently, the cause of death is respiratory failure or brain complications. Patients with disseminated disease have a poor prognosis, with a mean survival of approximately 6 months. Cure with any treatment is rare. Selection of treatment or a decision against treatment should be based on several factors, including the patient's medical condition, the potential for palliation, and the impact of treatment on quality of life.