56 NCCN Guidelines for Patients ® : Melanoma, 2018 5 Treatment guide In situ and local melanoma Primary treatment For stage 0, I, and II melanomas, the primary treatment is a wide excision. A wide excision is a surgery to remove the whole tumor and some normal-looking tissue around its edge. The normal- looking tissue is called the surgical margin. The size of the surgical margin depends on the thickness of the tumor. For lentigo maligna melanoma, different types of surgery may be used and wider margins may be needed, particularly on the face where tissue-sparing surgery is important. Under certain circumstances, surgery may not be possible for melanoma in situ, particularly lentigo maligna type on the face. In such cases, your doctor may discuss other treatment options. These may include topical imiquimod cream and local radiation therapy. (See Part 4 on page 35 for where to find each treatment type.) For thicker melanomas, you may also have a sentinel lymph node biopsy during surgery to remove the tumor. A sentinel lymph node biopsy removes the sentinel lymph node to test for cancer cells. The sentinel lymph node is the first lymph node to which cancer cells will likely spread from the primary tumor. If the sentinel lymph node biopsy finds cancer in the sentinel lymph node, the melanoma stage will be moved up (upstaged) to pathologic stage III. In this case, you will be treated for stage III melanoma instead of stage I or II. See Next steps at the end of this section. (Read Part 3 on page 29 for details and criteria of melanoma stages.) Adjuvant treatment For stage 0, IA, IB, and IIA tumors, adjuvant treatment after surgery isn’t needed. Instead, you will begin follow-up care or observation. During observation, scheduled follow-up testing will allow your doctor to watch you closely for cancer spread (metastasis) or return (recurrence). Most people with stage IIB or IIC are also watched closely for recurrence—including possible use of imaging tests for surveillance. In addition, another option for certain patients is to receive interferon alfa. It may be given at a high dose for one year as adjuvant treatment. Next steps For stage 0, I, or II melanoma, see Guide 10 on the next page for follow-up tests. For stage III, see Guide 11 on page 58 for follow-up tests. Guide 10 shows the follow-up tests and schedule that is recommended after completing treatment for stage 0, I, or II melanoma. Follow-up tests are used to monitor you after treatment to check for signs of recurrence or metastasis. A recurrence is when cancer comes back (recurs) after a period of time. Metastasis is when cancer spreads from the original (primary) tumor to other sites in the body. The tests and frequency of follow-up described in the chart are based on the risk of recurrence for each stage. Main follow-up tests are used for all stages of melanoma. First, you should have a complete skin exam by your doctor every year for life. You should also examine your own skin on a regular basis. And, you should check your lymph nodes during the self-exam of your skin. Imaging tests such as a CT, PET/CT, or MRI scan are only suggested if you have specific signs or symptoms of cancer that your doctor needs to check out. An ultrasound of nearby (regional) lymph nodes may be used for follow-up in certain situations. One is when the physical lymph node exam findings are unclear. The second is if you did not undergo the sentinel lymph node biopsy that was offered at the time melanoma was found (diagnosed). The third is if you did not have a complete lymph node dissection after the sentinel lymph node biopsy found cancer.