For Your Patients: Managing Recurrent Melanoma

Treatment for early-stage melanoma often leads to a cure, allowing most patients to lead normal, productive lives with good quality of life. Estimates vary, but melanoma returns, or recurs, in approximately 2-10% of cases, according to published studies. When melanoma does recur, effective treatment options exist. In some cases, treatment may be the same as for the original melanoma, such as surgery.

If melanoma does recur, it usually does so within 5 years after the original diagnosis, often within the first year. Most local or regional recurrences do not look like the original melanoma. Instead, the recurrence may appear as a lump under the skin, a dark spot near the primary tumor, or in the lymph nodes. Treatment will depend on the type of recurrence and the biological characteristics of the recurrent lesion.

Recurrence Near the Surgical Site (Scar)

As the name suggests, this type of recurrence arises in or around the scar from the surgery for the original tumor and suggests that cancer cells escaped despite surgery. In most cases, the recurrent lesion is found in the uppermost layers of the skin. A biopsy will confirm the diagnosis and inform decisions about additional testing that might be indicated, as well as the type of treatment.

Repeat surgery, with margins defined by the recurrent lesion's thickness and other features, often is sufficient for a recurrence in or around the scar of the initial melanoma.

Local Satellite/In-Transit Recurrence

These terms refer to melanoma recurrence in the lymph vessels, either within or adjacent to the original tumor scar (satellite) or between the original tumor and regional lymph nodes but not in the lymph nodes (in-transit). This type of recurrence usually appears as a firm bump in or near the original melanoma scar.

Evaluation of a local satellite or in-transit recurrence includes a biopsy, imaging to help define the extent of the lesion or evaluate associated signs and symptoms, and BRAF mutation testing, which can inform decisions about use of drug treatment.

Surgery is the first treatment consideration for local satellite/in-transit recurrence. Postoperatively, systemic drug therapy or observation might be appropriate. If surgery is not recommended, systemic therapy -- or occasionally, direct injection of a drug into the lesion -- might be used to treat the recurrence.

Nodal Recurrence

Nodal recurrence means the melanoma has returned in the lymph nodes, which may be diagnosed on an exam or on imaging. The evaluation includes a biopsy, imaging to determine the extent of the recurrence and evaluate specific signs or symptoms, and mutation testing. The approach to treatment varies according to whether the recurrence can be removed surgically and whether a complete lymph node dissection was performed as part of treatment for the original melanoma.

For patients with no prior lymph node dissection (not including sentinel lymph node biopsy), the initial approach to treatment is surgical removal of the lymph nodes in that area, which might be followed by systemic drug treatment, radiation therapy, or observation. If a patient previously underwent a lymph node dissection, the doctor will determine whether the recurrence can be treated surgically. If surgery is feasible, that will be the initial treatment, followed by drug therapy, radiation therapy, or observation. If the recurrence cannot be removed surgically (i.e., it is "unresectable"), systemic therapy is the preferred treatment option.

Systemic Disease

If the cancer has spread beyond the original tumor site to distant organs, the recurrence is systemic, sometimes called distant metastatic disease. This is considered Stage IV disease. Drug therapy is the standard approach to treatment, although surgery or other interventions, if feasible, may be helpful in some cases. Enrollment in a clinical trial also is an option for most patients with advanced melanoma.

Summary

Although treatment for early-stage melanoma often provides a cure, recurrence is a possibility. It is important for patients to follow-up as recommended with dermatology, surgical oncology, and medical oncology after the initial diagnosis. The important message for patients is that treatment options exist for recurrent melanoma, and that the treatment can be highly effective, particularly for limited recurrences.

Read previous installments in this series:

For Your Patients: What Is Melanoma?

For Your Patients: Is What You're Seeing Harmless or Is It Melanoma?

For Your Patients: Is It Melanoma or Something Else?

For Your Patients: What to Know about Treating Early-Stage Melanoma

For Your Patients: New Options, Better Outcomes for Advanced Melanoma

For Your Patients: Choosing the Right Therapy for Advanced Melanoma

"Medical Journeys" is a set of clinical resources reviewed by doctors, meant for physicians and other healthcare professionals as well as the patients they serve. Each episode of this 12-part journey through a disease state contains both a physician guide and a downloadable/printable patient resource. "Medical Journeys" chart a path each step of the way for physicians and patients and provide continual resources and support, as the caregiver team navigates the course of a disease.