AAD Guideline Update for Mx of Primary Cutaneous Melanoma
The American Academy of Dermatology (AAD) has updated its 2011 clinical practice guideline for the management of patients with primary cutaneous melanoma. The guidance has been published recently in the Journal of American Academy of Dermatology.

The guidelines include updated recommendations on treatment, biopsy techniques, histopathologic interpretation of cutaneous melanoma (CM). With regard to treatment of primary cutaneous melanoma, recommendations for surgical margins and the concepts of staged excision (including Mohs micrographic surgery) and nonsurgical treatments for melanoma in situ, lentigo maligna type (including topical imiquimod and radiation therapy), are updated.

Three new topics have been dealt with in the updated guidelines. These include melanoma in pregnancy, genetic testing for hereditary melanoma and multigene testing for mixed tumor syndromes that may include melanoma as a cancer. Furthermore, dermatologic toxicities associated with newer melanoma drugs are discussed along with data related to various molecular techniques, including gene expression profiling for both melanoma diagnosis and prognostication.

Some of the key recommendations are:-
• Preferred biopsy technique is a narrow excisional/ complete biopsy with 1- to 3-mm margins that encompass the entire breadth of lesion and is of sufficient depth to prevent transection at the base.

• This may be accomplished by fusiform/elliptical or punch excision or deep shave/saucerization removal to depth below the anticipated plane of the lesion. Partial/incomplete sampling (incisional biopsy) is acceptable in select clinical circumstances such as facial or acral location, very large lesion, or low clinical suspicion or uncertainty of diagnosis.

• Essential histologic features for inclusion in the pathology report
o Size of specimen
o Tumor thickness (Breslow), nearest 0.1 mm
o Ulceration
o Dermal mitotic rate; ‘‘hotspot’’ method; No. of mitoses/mm2
o Peripheral and deep margin status (negative/positive)
o Microsatellitosis

• Surgical excision with histologically negative margins is the recommended and first-line treatment for primary CM of any thickness, as well as for melanoma in situ. Surgical margins should be based on tumor thickness

• Surgical margins for invasive CM should be ≥1 cm and ≤cm measured clinically around the primary tumor, although margins may be narrower to accommodate function and/or anatomic location. Depth of excision is recommended to (but not including) the fascia.

• Sentinel lymph node biopsy, when indicated, should be performed before wide excision of the primary tumor, and in the same operative setting, whenever possible

• SLNB is not recommended for patients with MIS or for most T1a CM (<0.8 mm without ulceration per the eighth edition of the AJCC staging system)

• Radiologic imaging and laboratory studies for CM at baseline should be performed only to evaluate specific signs or symptoms of synchronous metastasis (regional nodal or distant).

• Topical imiquimod 5% cream may be used as second-line treatment for MIS, LM type, when surgery is not possible at the outset (primary setting) or when optimal surgery has been performed (adjuvant setting).

• In a pregnant woman with CM, a tailored, multidisciplinary approach to care that involves the obstetrician and CM specialists relevant to the patient’s stage of disease is recommended.

• A diagnosis of CM during pregnancy does not alter prognosis or outcome for the woman; however, work-up and treatment must take the safety of the fetus into consideration.

• Dermatologists should collaborate with oncologists for management of cutaneous toxicity during BRAF/MEK kinase or immune checkpoint inhibitor therapy because appropriate recognition and control of skin side effects may improve the quality of life of patients with CM and avoid unnecessary interruption of medication.


About AAD
The American Academy of Dermatology (AAD) is one of the largest organizations of dermatologists in the world. It was founded in 1938 and represents 19,000 dermatologists in the United States, Canada, and around the world. The academy grants fellowships and associate memberships, as well as fellowships for nonresidents of the United States or Canada. The AAD publishes a monthly medical journal, the Journal of the American Academy of Dermatology.

Note: This list is a brief compilation of some of the key recommendations included in the Guidelines and is not exhaustive and does not constitute medical advice. Kindly refer to the original publication here: https://pxmd.co/cVcp4
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