Members of the PracticeUpdate Oncology Advisory Board answer the most frequently asked questions by oncologists.

Question: How wide a margin should be obtained in the definitive surgical procedure?

Answer: If the depth of the melanoma is ≤ 1 mm, a 1-cm margin is sufficient; but, if the depth of the lesion is > 1 mm, a 2-cm margin should be considered and definitely obtained for lesions deeper than 2 mm.

Question: When should a sentinel node procedure be performed?

Answer: In patients with “adverse features”: lesions 0.75 mm or deeper (this is a relatively new recommendation, changed from 1.0 mm); those with positive deep margins; and those with lymphovascular invasion.

Question: What types of testing should be performed at the time of diagnosis?

Answer: In asymptomatic patients with stage I and II (node-negative) disease, no laboratory or imaging studies should be ordered. One should consider imaging (chest x-ray; CT or PET) and perhaps laboratory testing in stage III (node-positive) and IIB patients, especially if adjuvant therapy is being planned.

Question: What kind of follow-up is recommended for resected melanoma patients?

Answer: For patients with early-stage (I and IIA) disease, examination of the skin and regional lymph nodes is recommended every 3 to 12 months for at least 5 years and then annually. For higher-stage patients who are at more risk for developing recurrent or metastatic disease, one could consider adding a chest x-ray and/or CT/PET periodically.

Question: Who should receive adjuvant therapy and what kind?

Answer: The only approved adjuvant treatment in the US is high-dose interferon, which has limited efficacy. Patients are encouraged to enter a clinical trial, such as the ECOG E1609 adjuvant trial, offered nationally; this is studying ipilimumab vs interferon.

Question: What treatments are available for metastatic melanoma and how should they be used?

Answer: Options are increasing, and sequencing of the various agents is somewhat controversial. All patients should have their tumor specimen tested for the BRAF mutation, and, if it is present, a BRAF inhibitor should be offered initially or after failing immunotherapy. Ipilimumab or IL-2 is probably the most effective initial treatment. Chemotherapy should be reserved for second- or third-line treatment. Again, patients are encouraged to seek out clinical trials.