1. Melanoma Staging an update
Dr G Collin

2. Network melanoma imaging guidelines
Last updated June 2015
NICE recommendations July 2015
AJCC staging 8th edition December 2016

3. Melanoma survival by stage at presentation
2008 AJCC melanoma staging database

4. NICE – July 2015
SLNB
Consider sentinel lymph node biopsy as a staging rather than a therapeutic procedure for people with stage IB–IIC melanoma with a Breslow thickness of more than 1mm, and give them detailed verbal and written information about the possible advantages and disadvantages, using the table.

6. Cautions SLNB False positive / false negative rates
Primary tumour close to draining group

7. NICE
Do not routinely offer screening investigations (including imaging and blood tests) as part of follow-up to people who have had stages IB–IIB melanoma or stage IIC melanoma with a negative sentinel lymph node biopsy

8. NICE
Offer CT staging to people with stage IIC melanoma who have not had sentinel lymph node biopsy, and to people with stage III or suspected stage IV melanoma. Include the brain as part of imaging for people with suspected stage IV melanoma.
Consider whole-body MRI for children and young people (from birth to24 years) with stage III or suspected stage IV melanoma.

9. NICE
Consider surveillance imaging as part of follow-up for people who have had stage IIC melanoma with no sentinel lymph node biopsy or stage III melanoma and who would become eligible for systemic therapy as a result of early detection of metastatic disease if:
there is a clinical trial of the value of regular imaging or the specialist skin cancer multidisciplinary team agrees to a local policy and specific funding for imaging 6-monthly for 3 years is identified.

11. PET Not specifically mentioned in NICE guidance for melanoma
NICE PET guideline 2013:
Staging of patients with known disseminated melanoma to assess extent of disease prior to treatment
Assess for distant disease in patients with melanoma when radical dissection is contemplated.
Assess response to isolated limb infusion

12. Proposed Imaging Guidelines
Offer SLNB stage 1B to 2C
Offer surveillance CT 6 monthly for 3 years if diagnosis of recurrence would result in treatment change to patients with:
T4B tumours (>4mm with ulceration)
Any T stage with positive nodes (Stage 3)
?Except 1-2 micrometastasis on SLNB
Offer surveillance CT 6 monthly indefinitely:
Systemic metastases (Stage 4) if candidate for active treatment

13. Proposed Imaging Guidelines
US scanning
To assess clinically detected lumps and bumps
To assist in diagnosis of CT proven disease (biopsy)
MRI
To assess specific question not answered by CT
Consider whole body MRI as alternative for CT staging of patients under the age of 25
PET scanning
Not for routine staging
To arbitrate on equivocal CT imaging
Prior to major resection for localised disease (e.g. ilio-inguinal resection)