1. Stage IA T1aN0M0 no adverse features Breslow ≤ 1mm T1a: no ulceration (U-), Clark level ≤ III 10 yr survival = 87.9% MarginsMohs?SLN bxPETCTRadiation Adjuvant ESMO1 cmno NCCN1 cmno U of Iowa1 cm*no**no consider: PNI, desmoplasticno *comment: margins are not inviolate and may be modified by proximity to critical structures with attention to lymphatic drainage patterns **comment: Mohs surgery may be considered for melanoma with lentigo maligna extending beyond the 1 margin encompassing melanoma

2. Stage IA T1aN0M0 adverse features: mitotic rate >1 mm2, LVI Breslow ≤ 1mm T1a: no ulceration (U-), Clark level ≤ III MarginsMohs?SLN bxPETCTRadiation Adjuvant ESMO1 cmno NCCN1 cmnoyesno U of Iowa1 cm*no**yes***no consider: PNI, desmoplasticno *comment: margins are not inviolate and may be modified by proximity to critical structures with attention to lymphatic drainage patterns **comment: Mohs surgery may be considered for melanoma with lentigo maligna extending beyond the 1 margin encompassing melanoma ***comment: consider SLN bx: >0.75 mm invasion, other listed adverse features; SLN not useful desmoplastic melanoma

3. Stage IB T1bN0M0 Breslow ≤ 1mm T1b:with ulceration or Clark level IV or V MarginsMohs?SLN bxPETCTRadiation Adjuvant ESMO1 cmno NCCN1 cmnoyesno U of Iowa1 cm*no**yes***no consider: PNI, desmoplasticno *comment: margins are not inviolate and may be modified by proximity to critical structures with attention to lymphatic drainage patterns **comment: Mohs surgery may be considered for melanoma with lentigo maligna extending beyond the 1 margin encompassing melanoma ***comment: consider SLN bx: >0.75 mm invasion, other listed adverse features; SLN not useful desmoplastic melanoma

4. Stage IB T2aN0M0 Breslow 1.01-2.0 mm T2a: no ulceration MarginsMohs?SLN bx PE TCTRadiation Adjuvant ESMO NCCN1 - 2 cmnoyesno# no U of Iowa1 -2 cm*no**yes***no# consider: PNI, desmoplasticno *comment: margins are not inviolate and may be modified by proximity to critical structures with attention to lymphatic drainage patterns **comment: Mohs surgery may be considered for melanoma with lentigo maligna extending beyond the 1 margin encompassing melanoma ***comment: consider SLN bx: >0.75 mm invasion, other listed adverse features; SLN not useful desmoplastic melanoma #comment: PET/CT imaging may be useful to evaluate signs/symptoms but are not routine.

5. Stage IIA T2bN0M0 Breslow 1.01-2.0 mm T2b: with ulceration MarginsMohs?SLN bx PE TCTRadiation Adjuvant ESMO NCCN1 - 2 cmnoyesno# no U of Iowa1 -2 cm*no**yes***no# consider: PNI, desmoplasticno *comment: margins are not inviolate and may be modified by proximity to critical structures with attention to lymphatic drainage patterns **comment: Mohs surgery may be considered for melanoma with lentigo maligna extending beyond the 1 margin encompassing melanoma ***comment: consider SLN bx: >0.75 mm invasion, other listed adverse features; SLN not useful desmoplastic melanoma #comment: PET/CT imaging may be useful to evaluate signs/symptoms but are not routine.

6. Stage IIA T3aN0M0 Breslow 2.01-4.0 mm T3a: no ulceration MarginsMohs?SLN bx PE TCTRadiation Adjuvant ESMO NCCN2 cmnoyesno# no U of Iowa2 cm*no**yes***no# consider: PNI, desmoplasticno *comment: margins are not inviolate and may be modified by proximity to critical structures with attention to lymphatic drainage patterns **comment: Mohs surgery may be considered for melanoma with lentigo maligna extending beyond the 1 margin encompassing melanoma ***comment: consider SLN bx: >0.75 mm invasion, other listed adverse features; SLN not useful desmoplastic melanoma #comment: PET/CT imaging may be useful to evaluate signs/symptoms but are not routine.

7. Stage IIB T3bN0M0 Breslow 2.01-4.0 mm T3b: with ulceration MarginsMohs?SLN bx PE TCTRadiation Adjuvant ESMO NCCN2 cmnoyesno# no U of Iowa2 cm*no**yes***no# consider: PNI, desmoplasticno *comment: margins are not inviolate and may be modified by proximity to critical structures with attention to lymphatic drainage patterns **comment: Mohs surgery may be considered for melanoma with lentigo maligna extending beyond the 1 margin encompassing melanoma ***comment: consider SLN bx: >0.75 mm invasion, other listed adverse features; SLN not useful desmoplastic melanoma #comment: PET/CT imaging may be useful to evaluate signs/symptoms but are not routine.

8. Stage IIB T4aN0M0 Breslow >4.0 mm T4a: no ulceration MarginsMohs?SLN bx PE TCTRadiation Adjuvant ESMO NCCN2 cmnoyesno# no U of Iowa2 cm*no**yes***yes consider: PNI, desmoplasticno *comment: margins are not inviolate and may be modified by proximity to critical structures with attention to lymphatic drainage patterns **comment: Mohs surgery may be considered for melanoma with lentigo maligna extending beyond the 1 margin encompassing melanoma ***comment: consider SLN bx: >0.75 mm invasion, other listed adverse features; SLN not useful desmoplastic melanoma #comment: PET/CT imaging may be useful to evaluate signs/symptoms but are not routine.

9. Stage IIC T4bN0M0 Breslow >4.0 mm T4b: with ulceration MarginsMohs?SLN bx PE TCTRadiation Adjuvant ESMO NCCN2 cmnoyesno# no U of Iowa2 cm*no**yes***yes consider: PNI, desmoplasticno *comment: margins are not inviolate and may be modified by proximity to critical structures with attention to lymphatic drainage patterns **comment: Mohs surgery may be considered for melanoma with lentigo maligna extending beyond the 1 margin encompassing melanoma ***comment: consider SLN bx: >0.75 mm invasion, other listed adverse features; SLN not useful desmoplastic melanoma #comment: PET/CT imaging may be useful to evaluate signs/symptoms but are not routine.

10. Stage III T - any N - positive M - 0 MarginsMohs?SLN bxPETCTRadiation Adjuvant ESMO NCCNper Tno yes U of Iowaper T*no**noyes *comment: margins are not inviolate and may be modified by proximity to critical structures with attention to lymphatic drainage patterns **comment: Mohs surgery may be considered for melanoma with lentigo maligna extending beyond the 1 margin encompassing melanoma

11. Stage IV T - any N - any M - 0 MarginsMohs?SLN bxPETCTRadiation Adjuvant ESMO NCCNper Tno yes U of Iowaper T*no**noyes *comment: margins are not inviolate and may be modified by proximity to critical structures with attention to lymphatic drainage patterns **comment: Mohs surgery may be considered for melanoma with lentigo maligna extending beyond the 1 margin encompassing melanoma