For Patients

Few patients are prepared for a diagnosis of melanoma.  We are here to help you through the diagnosis.  We employ the most up-to-date and advanced therapeutic options available.

What to know after the diagnosis of melanoma:

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Initial Evaluation

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A melanoma diagnosis begins with a complete medical and family history, including prior skin cancers, sunburns, and inherited conditions. A thorough head-to-toe skin examination by an experienced dermatologist is essential, often using dermoscopy (magnified viewing) to evaluate suspicious lesions.

Biopsy: Definitive diagnosis requires a skin biopsy. An excisional (complete) biopsy is strongly preferred, removing the entire lesion with a narrow margin using elliptical excision, punch, or deep shave (saucerization) technique. The specimen is sent to a dermatopathologist who evaluates critical prognostic factors:

- Breslow thickness (depth in millimeters)—the single most important prognostic factor

- Ulceration status—breakdown of overlying skin indicates higher risk

- Mitotic rate—how rapidly cancer cells are dividing

- Margin status—whether tumor extends to specimen edges

- Microsatellitosis—microscopic tumor deposits in nearby lymphatics

- Other features—lymphovascular invasion, neurotropism, desmoplastic features

Staging Workup: Melanoma uses the AJCC TNM staging system. Clinical staging occurs after biopsy; pathologic staging follows definitive surgery. Staging determines treatment:

- Stages 0–II (early): Localized to skin

- Stage III (regional): Lymph node, satellite, or in-transit involvement

- Stage IV (metastatic): Distant spread to organs

For thicker or higher-risk melanomas, additional evaluation may include:

- Sentinel lymph node biopsy (SLNB): Samples first draining lymph node(s), typically for tumors ≥1 mm thick or thinner lesions with high-risk features

- Imaging (CT, PET/CT, MRI): Not routine for early disease but used for advanced stages or concerning symptoms

- Biomarker testing: For stage III–IV disease, testing for BRAF, NRAS, and KIT mutations guides targeted therapy options

Treatment by Stage

Stage 0 (In Situ):

Wide local excision with 0.5–1 cm margins is standard. Mohs surgery or staged excision may be considered for cosmetically or functionally sensitive areas (face, ears). Topical imiquimod or radiation therapy are rarely used alternatives when surgery isn't feasible.

Stage I–II (Early Invasive):

Treatment centers on surgery:

- Wide local excision with margins based on Breslow depth (typically 1–2 cm)

- SLNB for tumors ≥1 mm or high-risk thinner lesions (ulceration, high mitotic rate)

- Adjuvant immunotherapy with pembrolizumab or nivolumab for stage IIB–IIC reduces recurrence risk but carries immune-related side effects; decision requires shared discussion of benefits versus toxicities

Stage III (Regional):

Multimodal approach with surgery plus systemic therapy:

- Neoadjuvant therapy (before surgery) increasingly preferred: immunotherapy (nivolumab ± ipilimumab) or BRAF/MEK inhibitors for BRAF-mutant disease can shrink tumors and improve surgical outcomes

- Wide excision of primary site if not previously done

- Lymph node management: Therapeutic lymph node dissection for clinically involved nodes; completion dissection after positive SLNB is now often replaced by surveillance

- Adjuvant therapy: Immunotherapy (nivolumab, pembrolizumab) or targeted therapy (dabrafenib-trametinib for BRAF-mutant) for 1 year reduces recurrence

- In-transit/satellite lesions: May receive intralesional T-VEC (oncolytic virus therapy), isolated limb perfusion, radiation, or excision

Stage IV (Metastatic):

Systemic therapy is the cornerstone, with surgery and radiation for select cases:

Immunotherapy options:

- Single-agent PD-1 inhibitors (pembrolizumab, nivolumab)

- Combination regimens (nivolumab-ipilimumab or nivolumab-relatlimab) offer higher response rates but more toxicity

- Intralesional T-VEC for injectable lesions

Targeted therapy (BRAF-mutant only):

- BRAF/MEK inhibitor combinations (dabrafenib-trametinib, encorafenib-binimetinib, vemurafenib-cobimetinib) provide rapid responses but eventual resistance

Multidisciplinary Care

Optimal melanoma management requires a team including dermatology, surgical oncology, medical oncology, radiation oncology, dermatopathology, plastic surgery, genetics, palliative care, nursing, social work, and mental health professionals.  All of which are utilized during and after your care at Revive Palmetto.

Follow-Up

Stage-dependent surveillance includes periodic history, physical exam with full skin checks, and nodal assessment. Imaging is reserved for high-risk patients or symptoms and is not recommended indefinitely. Lifelong skin self-exams using the ABCDE rule (Asymmetry, Border irregularity, Color variation, Diameter >6 mm, Evolving) and the "ugly duckling" sign help detect recurrence or new primaries.

Key Takeaways

Melanoma caught early is highly curable with surgery alone. Advanced disease now has effective systemic options—immunotherapy and targeted therapy have transformed outcomes over the past decade. Treatment should be individualized based on stage, molecular profile, patient preferences, and access to clinical trials. Patient advocacy, second opinions at melanoma centers of excellence, and engagement with support organizations (AIM at Melanoma, Melanoma Research Foundation, NCCN patient resources) optimize care and quality of life throughout the cancer journey.