In 2008, an estimated 62,480 new cases of melanoma will have been diagnosed and approximately 8420 patients will have died of the disease in the United States. The incidence of melanoma continues to increase dramatically. Risk factors for melanoma include family history of melanoma, prior melanoma, multiple clinically atypical moles or dysplastic nevi, inherited genetic mutations, and sun exposure. Individuals unable to tan and those with fair skin that sunburns easily have a greater risk for developing melanoma. However, melanoma can occur in any ethnic group and also in areas of the body that have not had substantial sun exposure. As with nearly all malignancies, the outcome of melanoma initially depends on the stage at presentation. The NCCN Melanoma guidelines attempt to distill and simplify an enormous body of knowledge and experience into fairly simple management algorithms.

Merkel Cell Carcinoma

The NCCN Non‑Melanoma Skin Cancer Panel has developed guidelines outlining treatment of Merkel Cell Carcinoma (MCC) to supplement the NCCN Squamous Cell and Basal Cell Skin Cancer Guidelines (to view the most recent version, visit the NCCN Web site at NCCN.org). Merkel cell carcinoma (MCC) is a rare, aggressive cutaneous tumor that combines the local recurrence rates of infiltrative non-melanoma skin cancer with the regional and distant metastatic rates of thick melanoma. Because it rare, no prospective, statistically significant data are available to verify the validity of any prognostic features or treatment outcomes. MCC has a mortality rate that exceeds that of melanoma, with overall 5‑year survival rates from 30% to 64%.

Special Feature

PET/CT and Occult Primary Tumors
Donald A. Podoloff, MD

Within the past 5 years, F-18 fluorodeoxyglucose FDG PET/CT has become one of the more frequent imaging modalities in the management of patients with cancer of unknown primary origin. FDG PET/CT detects more sites of metastasis than other modalities, and in 20% to 40% of cases it discloses the site of the primary tumor. Its exact role is yet to be defined because of a lack of prospective clinical trials comparing the performance of PET/CT with conventional anatomic imaging modalities. This article reviews the available literature and attempts to place PET/CT using F-18 labeled FDG in clinical perspective, and compares the combined modality with conventional anatomic imaging technologies.

Featured Articles

Review of Evidence-Based Support for Pretreatment Imaging in Melanoma
Michael S. Sabel, MD, and Sandra L. Wong, MD

When making a new diagnosis of melanoma, clinicians often obtain imaging studies to rule out clinically occult distant disease. These studies range from chest radiographs to the more expensive PET/CT. The impetus for ordering these studies is usually the desire to identify potentially resectable distant disease, avoid surgery when curative resection is not possible, and assuage patient anxiety by showing that no evidence of distant disease is present. However, some detrimental aspects to these studies are less apparent, including cost and potential for false-positive findings. Although routine use seems reasonable, the true benefit of these studies depends on the probability of clinically occult disease being present, likelihood that disease will be detected with the available technology, and impact of earlier detection on outcome. Contrary to current practice patterns, available evidence suggests that preoperative imaging studies are associated with significant costs and minimal benefit in most patients with melanoma. This article reviews available literature on the role of pretreatment imaging in patients with newly diagnosed cutaneous melanoma.

Where Are We With Adjuvant Therapy of Stage III and IV Melanoma in 2009?
Leslie A. Fecher, MD, and Keith T. Flaherty, MD

Adjuvant therapy options for advanced melanoma in 2009 remain active observation, high-dose interferon, or clinical trial participation. Close observation is currently the only required adjuvant management, with the purpose of detecting the emergence of regional or metastatic disease early, when surgical management may still be possible. The National Comprehensive Cancer Network guidelines for the workup and follow-up of all stages of melanoma must be tailored to specific patients at the discretion of the treating physician. This article explores the factors to consider when individualizing care within the scope of these guidelines.

The Role of Sentinel Lymph Node Biopsy in Patients with Thin Melanoma
Robert H. I. Andtbacka, MD, and Jeffrey E. Gershenwald, MD

The use of sentinel lymph node (SLN) biopsy in patients with thin melanoma is controversial. Experts have suggested that SLN biopsy is not indicated because of the low incidence of nodal metastasis, risk for morbidity (albeit low) associated with the procedure, and associated cost. However, several studies investigating the risk for SLN involvement in patients with thin melanoma have shown that a subset of patients are at sufficient risk for positive SLNs at initial diagnosis to justify SLN biopsy. A key challenge is how best to define this patient subset. To date, no clear consensus exists regarding which prognostic factors best predict the risk for SLN metastasis in patients with thin melanoma, what constitutes “high risk” for SLN metastasis, and which prognostic factors should be used in clinical decision-making about SLN biopsy. This article reviews the current literature on SLN biopsy in thin melanoma to clarify predictors of SLN metastasis and resolve some uncertainty surrounding which patients with thin melanomas should be offered SLN biopsy.

Merkel Cell Carcinoma: A Review of Current Advances
Frank Qian Zhan, MD;Vathani Sharon Packianathan, BS; and Nathalie Charlotte Zeitouni, MDCM, FRCPC

Merkel cell carcinoma (MCC) is a rare but aggressive cutaneous malignancy of neuroendocrine origin. It mainly affects elderly individuals and is associated with a high mortality rate. Its incidence has tripled over the past 2 decades. Because of this tumor’s high rate of metastasis and mortality, the efficacy of lesion thickness and sentinel lymph node biopsy in the TNM staging system has been examined extensively. In a similar fashion, its treatment recommendations have evolved from monotherapy with wide local excision to a multidisciplinary approach involving a combination of surgery, radiation therapy, and chemotherapy. Furthermore, recent discoveries suggest a viral origin in the pathogenesis of MCC. This article reviews the new discoveries in MCC’s etiology, proposed acronym to aid in clinical diagnosis, current tumor staging system, and improvements in multidisciplinary management.

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