Melanoma diagnosis and treatment
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Melanoma Diagnosis: Clinical Assessment, Dermatoscopy, and Histopathology
Melanoma is the deadliest form of skin cancer, making early and accurate diagnosis essential for improving patient outcomes Davis2019Ahmed2020. Diagnosis typically begins with a clinical assessment, often using dermatoscopy to examine suspicious pigmented lesions Garbe2012Garbe2009Garbe2012+2 MORE. If melanoma is suspected, confirmation through histopathological examination is always required Garbe2020Garbe2022. For high-risk patients, sequential digital dermatoscopy and full-body photography can help detect melanomas at an earlier stage, and confocal reflectance microscopy may be used in special cases to improve diagnostic accuracy Garbe2020Garbe2022.
Melanomas are classified according to the American Joint Committee on Cancer (AJCC) system, which guides further management Garbe2012Garbe2009Garbe2012+2 MORE. Thin melanomas (up to 0.8 mm) generally do not require additional imaging, while more advanced stages may require lymph node sonography, CT, PET-CT, or brain MRI to assess for metastasis Garbe2020Garbe2022. Mutation testing, especially for BRAF V600, is recommended from stage III and higher Garbe2020Garbe2022.
Melanoma Treatment: Surgery, Adjuvant Therapy, and Systemic Options
Surgical Excision and Sentinel Lymph Node Biopsy
The primary treatment for early-stage melanoma is surgical excision with 1–2 cm safety margins Garbe2012Garbe2009Garbe2012+4 MORE. Sentinel lymph node biopsy is recommended for tumors ≥1.0 mm thick or ≥0.8 mm with additional risk factors, although there is no clear survival benefit for this procedure Garbe2012Garbe2009Garbe2012+3 MORE.
Adjuvant and Neoadjuvant Therapies
For patients with completely resected stage IIB–IV melanoma, adjuvant therapies can be considered. In stage II, PD-1 inhibitors are approved, while in stage III, anti-PD-1 therapy or dabrafenib plus trametinib (for BRAFV600-mutated melanoma) are options Garbe2024Garbe2019Garbe2022. Neoadjuvant therapy with immune checkpoint inhibitors (such as ipilimumab plus nivolumab or pembrolizumab) may be offered in selected cases, followed by surgery and further adjuvant therapy based on response and BRAF status .
Systemic Treatment for Advanced Melanoma
For unresectable stage III/IV melanoma, systemic treatment is always indicated. First-line options for BRAF wild-type patients include immunotherapy with PD-1 antibodies alone or in combination with CTLA-4 or LAG-3 antibodies Garbe2024Garbe2019Garbe2022. For patients with BRAFV600 mutations, BRAF/MEK inhibitors (such as dabrafenib plus trametinib) can be used as first- or second-line therapy, especially if there is resistance to immunotherapy Garbe2024Garbe2019Garbe2022. Other second-line therapies include tumor-infiltrating lymphocyte therapy and combinations of immune checkpoint inhibitors not used in first line .
Multidisciplinary Decision-Making
Therapeutic decisions, especially in advanced stages, should be made by an interdisciplinary oncology team or "Tumor Board" to ensure optimal, individualized care Garbe2012Garbe2009Garbe2012+3 MORE.
Follow-Up and Prevention
Structured follow-up is important to detect relapses and new primary melanomas early, though the optimal frequency and extent of follow-up are not clearly defined Garbe2020Garbe2022. Preventive measures, such as reducing UV exposure, are crucial for lowering melanoma risk .
Ongoing Challenges and Future Directions
While new drugs and immunotherapies have improved outcomes for metastatic melanoma, many patients do not experience lasting responses, highlighting the need for new biomarkers and drug targets to further enhance diagnosis and treatment . The landscape of systemic therapy is rapidly evolving, and ongoing research continues to refine best practices Garbe2019Garbe2022.
Conclusion
Early and accurate diagnosis of melanoma, primarily through clinical assessment, dermatoscopy, and histopathology, is critical for improving survival. Surgical excision remains the cornerstone of treatment for early-stage disease, while advanced melanoma requires a combination of surgery, adjuvant therapies, and systemic treatments tailored to tumor characteristics and patient needs. Multidisciplinary care and ongoing research are essential to further improve outcomes for melanoma patients Davis2019Garbe2012Garbe2009+7 MORE.
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