Practice Guidelines in Oncology - MMMP

1 NCCN Clinical Practice Guidelines in Oncology . Melanoma Continue Guidelines Index NCCN.. Practice Guidelines Melanoma Table of Contents in Oncology Melanoma Staging, Discussion, References NCCN Melanoma Panel Members * Daniel G. Coit, MD/Chair Mohammed Kashani-Sabet, MD v Jeffrey A. Sosman, MD . Memorial Sloan-Kettering Cancer Center UCSF Helen Diller Family Vanderbilt-Ingram Cancer Center Comprehensive Cancer Center Robert Andtbacka, MD Susan M. Swetter, MD v Huntsman Cancer Institute Julie R. Lange, MD , ScM Stanford Comprehensive Cancer at the University of Utah The Sidney Kimmel Comprehensive Center Cancer Center at Johns Hopkins Christopher K. Bichakjian, MD v Kenneth K. Tanabe, MD . University of Michigan Anne Lind, MD Massachusetts General Hospital Comprehensive Cancer Center Siteman Cancer Center at Barnes-Jewish Cancer Center Hospital and Washington University School of Medicine * John A.

2 Thompson, MD . Raza A. Dilawari, MD . Fred Hutchinson Cancer Research St. Jude Children's Research Hospital/. Lainie Martin, MD Center/Seattle Cancer Care Alliance University of Tennessee Cancer Institute Fox Chase Cancer Center Vijay Trisal, MD . Dominick DiMaio, MD City of Hope Mary C. Martini, MD v UNMC Eppley Cancer Center Robert H. Lurie Comprehensive Cancer at The Nebraska Medical Center Center of Northwestern University Marshall M. Urist, MD . University of Alabama at Birmingham Valerie Guild Scott K. Pruitt, MD, PhD Comprehensive Cancer Center Consultant Duke Comprehensive Cancer Center Jeffrey Weber, MD, PhD . Allan C. Halpern, MD v Merrick I. Ross, MD H. Lee Moffitt Cancer Center &. Memorial Sloan-Kettering Cancer Center The University of Texas Research Institute M. D. Anderson Cancer Center F. Stephen Hodi, MD Michael K.

3 Wong, MD, PhD . Dana-Farber/Brigham and Women's Stephen F. Sener, MD Roswell Park Cancer Institute Cancer Center Robert H. Lurie Comprehensive Cancer Center of Northwestern University Medical Oncology Internal medicine v Dermatology Surgery/Surgical Oncology Continue Pathology Patient Advocacy Hematology/Hematology Oncology NCCN Guidelines Panel Disclosures * Writing Committee member Version , 11/17/08 2008 National Comprehensive Cancer Network, Inc. All rights reserved. These Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. Guidelines Index NCCN.. Practice Guidelines Melanoma Table of Contents in Oncology Melanoma Staging, Discussion, References Table of Contents NCCN Melanoma Panel Members For help using these Summary of Guidelines Updates documents, please click here Clinical Presentation and Preliminary Workup (ME-1).

4 Staging Stage 0 (in situ), Stage I-II (ME-2). Discussion Stage III (ME-3). References Stage IV (ME-4). Follow-up (ME-5) Clinical Trials: The NCCN. Persistent disease or True local scar recurrence, In-transit recurrence (ME-6) believes that the best management for any cancer patient is in a clinical Nodal recurrence (ME-7) trial. Participation in clinical trials is especially encouraged. Distant metastatic disease (ME-8). To find clinical trials online at NCCN. Principles of Biopsy (ME-A) member institutions, click here: Principles of Surgical Margins for Wide Excision of Primary Melanoma (ME-B) Complete Lymph Node Dissection (ME-C) NCCN Categories of Evidence and Consensus: All recommendations Principles of Systemic Therapy for Advanced or Metastatic Melanoma (ME-D) are Category 2A unless otherwise specified. See NCCN Categories of Evidence Guidelines Index and Consensus Print the Melanoma Guideline These Guidelines are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment.

5 Any clinician seeking to apply or consult these Guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient's care or treatment. The National Comprehensive Cancer Network makes no representations nor warranties of any kind whatsoever regarding their content, use, or application and disclaims any responsibility for their application or use in any way. These Guidelines are copyrighted by National Comprehensive Cancer Network. All rights reserved. These Guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN. 2008. Version , 11/17/08 2008 National Comprehensive Cancer Network, Inc. All rights reserved. These Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.

6 Guidelines Index NCCN.. Practice Guidelines Melanoma Table of Contents in Oncology Melanoma Staging, Discussion, References Summary of the Guidelines Updates Summary of changes in the version of the Melanoma Guidelines from the version is the addition of the Discussion. Summary of changes in the version of the Melanoma Guidelines from the version include: (ME-1). Pathology Report: Mitotic rate moved to third in the list and Clark level was moved to the bottom of the list. Footnote d : ..extensive regression and mitotic rate greater than zero was changed to ..lymphovascular invasion (LVI) or mitotic rate 1 mm 2.. (ME-2). Stage IA with adverse features; Workup: Further imaging only to was changed to Imaging only to . Footnote h stating Sentinel node biopsy is an important staging tool, but the impact of SLNB on overall survival is unclear is new to the page.

7 (ME-3). Clinical/Pathologic Stage; Stage III pathways: The phrases Nodal micrometastases and Nodal macrometastases were removed. (ME-5). Clinical/Pathologic Stage: Stage IB-III was changed to Stage IB-IV, NED . Stage I-IV, NED; Follow-up: Chest x-ray, LDH, CBC every 3 - 12 was changed to ..every 6 - 12 . (ME-6). Persistent disease pathway; Far Right: Recommendations should be stage was changed to Recommendations should be based on stage of . (ME-A): Principles of Biopsy Footnote 1 stating If clinical evaluation of incisional biopsy suggests that microstaging is inadequate, consider narrow margin excision is new to the page. (ME-B): Principles of Surgical Margins for Wide Excision of Primary Melanoma Footnote 2 stating Clinical margins may not correlate with histologic margins is new to the page. (ME-C): Complete Lymph Node Dissection First Bullet: A thorough was changed to An anatomically complete.

8 Footnote 1 stating Anatomic boundaries of lymph node dissection should be described in operative report is new to the page. Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Version , 11/17/08 2008 National Comprehensive Cancer Network, Inc. All rights reserved. These Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. UPDATES. Guidelines Index NCCN.. Practice Guidelines Melanoma Table of Contents in Oncology Melanoma Staging, Discussion, References CLINICAL PATHOLOGY PRELIMINARY CLINICAL STAGE. PRESENTATION REPORT WORKUP. Stage 0 in situ or Stage IA ( 1 mm thick, Clark level II or III) with no adverse features d (ME-2).

9 Stage IA ( 1 mm thick, Breslow Clark level II or III) with thickness adverse features d + (ME-2). Inadequate b Rebiopsy Ulceration status H&P with +. attention to Suspicious Mitotic rate Stage IB, Stage II. locoregional ( 1 mm thick with pigmented Biopsy a (category 2B). area, draining ulceration or Clark level lesion +. lymph nodes IV, V or > 1 mm thick, Assess deep and Melanoma Complete skin any characteristic), N0. peripheral confirmed b exam (ME-2). margin status Assessment of +. Satellitosis, if melanoma Stage III. present, should related risk (Sentinel node positive). be reported factors c (ME-3). +. Clark level (for Stage III. lesions 1 mm) Clinically positive nodes (ME-3). Stage III. a See Principles of Biopsy (ME-A). in-transit (ME-3). b If diagnostic biopsy is inadequate for treatment decisions, rebiopsy may be appropriate.

10 C Risk factors for melanoma include family history of melanoma, prior primary melanoma, and other factors such as atypical moles/dysplastic nevi. Stage IV. d Adverse features include positive deep margins, lymphovascular invasion (LVI) or mitotic rate 1 mm 2. Metastatic (ME-4). Note: All recommendations are category 2A unless otherwise indicated. Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. Version , 11/17/08 2008 National Comprehensive Cancer Network, Inc. All rights reserved. These Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN. ME-1. Guidelines Index NCCN.. Practice Guidelines Melanoma Table of Contents in Oncology Melanoma Staging, Discussion, References CLINICAL STAGE WORKUP PRIMARY TREATMENT ADJUVANT TREATMENT.