- True local recurrence:
- Is defined as recurrence at the site of the primary tumor, within or continuous with the scar:
- It is most likely the result of incomplete excision of the primary tumor
- It represents a relatively rare pattern of recurrence
- Is defined as recurrence at the site of the primary tumor, within or continuous with the scar:
- In many cases, such “local recurrences”:
- May more appropriately be considered persistence of the primary tumor
- A local recurrence consisting of a single lesion in a patient whose primary melanoma had favorable prognostic features:
- May be appropriately treated with wide excision similar to a primary melanoma lesion
- Patients with local recurrences consisting of multiple, small, and superficial lesions may be treated in a fashion similar to that used to treat patients with in-transit disease
- Definition of Local Recurrence:
- Local recurrence in cutaneous melanoma refers to the reappearance of melanoma at or near the site of the original primary tumor:
- Typically within 2 cm of the initial surgical scar, in the absence of regional or distant metastasis
- Local recurrence in cutaneous melanoma refers to the reappearance of melanoma at or near the site of the original primary tumor:
- Evaluation and Staging:
- Before initiating treatment:
- Clinical examination:
- Thorough skin and lymph node examination
- Imaging:
- PET-CT or CT/MRI to rule out regional or distant metastases
- Biopsy:
- Confirm recurrence histologically
- Restaging:
- Based on AJCC 8th Edition Melanoma Staging System
- Clinical examination:
- Before initiating treatment:
- Surgical Management:
- Surgery remains the cornerstone of treatment:
- Wide Local Excision (WLE):
- Excision with clear margins:
- Typically 1 to 2 cm based on Breslow depth
- May include re-excision if margins were inadequate in prior surgery
- Excision with clear margins:
- Wide Local Excision (WLE):
- Reconstruction:
- May be required depending on the anatomical location and size of excision
- Sentinel Lymph Node Biopsy (SLNB):
- Consider SLNB in recurrent lesions if not performed previously:
- Particularly in patients with intermediate or thick lesions:
- Offers prognostic information and can alter staging
- Particularly in patients with intermediate or thick lesions:
- Consider SLNB in recurrent lesions if not performed previously:
- Surgery remains the cornerstone of treatment:
- Adjuvant Therapy:
- Based on risk of recurrence, pathological findings, and prior treatments:
- Immunotherapy:
- Anti-PD-1 agents like nivolumab or pembrolizumab
- Targeted therapy:
- For BRAF V600-mutant melanoma:
- Dabrafenib + trametinib
- For BRAF V600-mutant melanoma:
- Radiotherapy:
- May be used postoperatively for high-risk features:
- Positive margins, perineural invasion, multiple recurrences
- May be used postoperatively for high-risk features:
- Regional and Systemic Therapy for Unresectable Recurrence
- If the recurrence is not surgically resectable or has multiple in-transit metastases:
- Intralesional therapy:
- T-VEC – talimogene laherparepvec
- Systemic immunotherapy or targeted therapy:
- Clinical trials may offer novel therapies
- Intralesional therapy:
- Immunotherapy:
- Based on risk of recurrence, pathological findings, and prior treatments:
- Surveillance:
- Regular follow-up is essential due to the risk of further recurrences or metastasis
- Typical schedule:
- Every 3 to 6 months for the first 2 to 3 years
- Annually thereafter
- Includes skin checks, lymph node exams, and imaging when indicated
- Prognostic Factors:
- Breslow thickness of recurrence
- Ulceration
- Time to recurrence
- Prior sentinel node involvement
- Genetic mutations (BRAF, NRAS)
- Multidisciplinary Management:
- Patients with recurrent melanoma should ideally be managed in a melanoma or skin cancer multidisciplinary team (MDT) setting involving:
- Dermatology
- Surgical oncology
- Medical oncology
- Radiation oncology
- Pathology and radiology
- Patients with recurrent melanoma should ideally be managed in a melanoma or skin cancer multidisciplinary team (MDT) setting involving:
Rodrigo Arrangoiz MS, MD, FACS, FSSO 