SAN DIEGO — When it comes to follow-up surveillance of melanoma patients, history and physical examination remain the cornerstone of good care, with little solid evidence to support anything else.
“The literature on this aspect of melanoma management is incomplete, mainly because there are very few prospective studies,” Dr. Peter R. Shumaker said at a melanoma update sponsored by the Scripps Clinic. He discussed several goals for postoperative follow-up:
▸ Earliest possible detection of treatable recurrence. About one-quarter of patients with local disease and 60%–70% of patients with in-transit [and] nodal disease will develop recurrence, said Dr. Shumaker, clinical fellow in procedural dermatology at the Scripps Clinic in La Jolla, Calif.
One study that reviewed the rate of first recurrence after treatment for malignant melanoma in 250 Australian patients found that 52% of recurrences were in the regional lymph nodes, 17% were local, 8% were in-transit, and 23% were visceral (Plast. Reconstr. Surg. 1993;91:94–8). Most recurrences occur within the first couple of years, he said, adding that patients are never considered unequivocally cured.
▸ Detection of other primary skin cancers. “These patients are at high risk for a second primary melanoma,” Dr. Shumaker warned.
▸ Patient education, emotional support, and reassurance. Most data show that at least half of recurrences are found by the patients themselves, despite being in a structured follow-up program. “These follow-ups, [provide] an opportunity to inspect and palpate lesions [and] educate patients.”
▸ Quality assurance. By this Dr. Shumaker meant the collection of data to improve future treatment and surveillance strategies, such as blood tests and imaging techniques. Chest x-rays and blood tests are often used in the routine follow-up of melanoma patients, “but offer little benefit in terms of cost effectiveness,” he said. They generally provide low sensitivity and a high rate of false positives. “Even if occult metastases are found, there is no clear evidence that there is an overall survival benefit with these tests. Even if abnormal, blood tests are rarely the sole indicator of recurrent disease.”
Dr. Shumaker considers 18fluorodeoxy-glucose positron emission tomography (FDG-PET) combined with computed tomography a “promising” whole-body imaging technique for follow-up in high-risk patients or in symptomatic patients at any stage. The technique can detect subclinical metastases because of their elevated metabolic activity but has limited sensitivity in tumors 5 mm or smaller.
Ultrasound seems “more sensitive than physical exam in detecting tumor recurrence in in-transit routes and regional nodal basins. There is an increased likelihood of survival benefit from asymptomatic detection in these areas.” He noted that ultrasound can be combined with fine-needle aspiration to diagnose recurrent or metastatic disease, but there appears to be no role for abdominal ultrasound in routine follow-up.
At Scripps, Dr. Shumaker and his associates perform a comprehensive history and physical exam in melanoma patients every 3 months for 3 years, then every 6 months for life. “This includes baseline and an annual chest x-ray and lab tests,” he said.
They refer patients with high-risk, thick melanomas to their colleagues in hematology/oncology. “We have a very low threshold for obtaining additional studies in symptomatic patients. Many patients with high-risk melanoma have a baseline FDG-PET/CT scan. You could consider that for your high-risk patients in follow-up.”
Most data show that at least half of recurrencesare found by the patients themselves. DR. SHUMAKER