Melanoma: assessment and management NICE guideline NG14 Full guideline July 2015

Dermoscopy for all pigmented lesions by individuals trained in the technique Medical Photography including dermoscopic image

Measure Vitamin D levels at diagnosis. Supplementation as necessary. Inform GP 25OHD thresholds: 50 nmol/l is sufficient for almost the whole population. Melanoma in situ at least 5mm clinical WLE margins Consider topical imiquimod to treat stage 0 melanoma if surgery to remove the entire lesion with a 0.5 cm clinical margin would lead to unacceptable disfigurement or morbidity. Repeat biopsies after treatment to assess response 1cm WLE for Stage 1 and 2cm WLE Stage 2 Offer as staging SLNB to IB to IIC. Do not offer for 1mm or less CT staging for IIC, III and IV (MRI <24 years-old)

Measure Vitamin D levels at diagnosis. Supplementation as necessary. Inform GP following serum 25OHD thresholds: 50 nmol/l is sufficient for almost the whole population. Melanoma in situ at least 5mm WLE margins Consider topical imiquimod to treat stage 0 melanoma if surgery to remove the entire lesion with a 0.5 cm clinical margin would lead to unacceptable disfigurement or morbidity. Repeat biopsies after treatment to assess response 1cm WLE for Stage 1 and 2cm WLE Stage 2 Offer as staging SLNB for IB to IIC. Do not offer for 1mm or less CT staging for IIC, III and IV (MRI <24 years-old)

All patients to be given verbal and written information on the advantages and disadvantages of SLNB (page 111) Consider completion lymphadenectomy if SLNB positive but also give verbal and written information on advantages and disadvantages

Do not give adjuvant radiotherapy in Stage III disease unless a reduction in the risk of local recurrence is estimated to outweigh the risk of serious adverse effects

Genetic Testing Do not offer genetic testing of stage IA– IIB primary melanoma at presentation except as part of a clinical trial. (less than 4mm thick with ulceration or greater than 4mm thick without ulceration no BRAF testing) Consider genetic testing of stage IIC primary melanoma or the nodal deposits or in-transit metastases for people with stage III melanoma. If insufficient tissue is available from nodal deposits or in transit metastases, consider genetic testing of the primary tumour for people with stage III melanoma.

FU Stage 0. Discharge after completing treatment. IA no mitoses 2 to 4 FUs in year 1 then discharge IB-IIC (SLNB Neg) 3 monthly for 3 years then 6 monthly for 2-years and discharge after 5 years

Those that may benefit from early intervention (IIC, III, early IV) consider surveillance imaging six monthly for 3-years. Explain pros and cons. (page 220) Decided by local policy and funding.