62 NCCN Guidelines for Patients ® : Melanoma, 2018 5 Treatment guide Regional melanoma Guide 13 shows the response assessment and next treatment options for stage III clinical satellite or in-transit melanoma. After primary treatment, your doctor will give imaging tests to check how well treatment worked. An outcome or improvement caused by treatment is called a treatment response. Based on these tests, you may have adjuvant treatment if there are no signs of cancer. If you had surgery as primary treatment and there are no signs of cancer, then you have several options for adjuvant treatment. You can begin observation; receive nivolumab, dabrafenib, and trametinib if you have a BRAF V600–activating mutation, or you can receive interferon alfa. Interferon alpha would be given at a high dose for one year or at smaller doses for up to 5 years. Observation is a period of scheduled follow-up testing to watch for cancer metastasis or recurrence. (See Part 4 on page 35 for details on each type of treatment.) If you had surgery but the cancer was not able to be fully resected, you have second-line treatments as an option. They include systemic therapy, local therapy options with T-VEC, BCG, interferon alfa, or IL-2 injections into the tumor or imiquimod cream rubbed onto the tumor. These are immunotherapy drugs and may be good options if you have clinical satellite or in-transit metastases. Your doctor may consider palliative radiation to relieve symptoms if the cancer can’t be removed by surgery. A regional therapy option is isolated limb infusion/perfusion with the chemotherapy drug melphalan. The drug is infused into the arm or leg during a surgical procedure. If you had treatment other than surgery as your primary treatment and the disease is progressing or responding to treatment, you would have the same options as you would for disease that couldn’t be fully removed by surgery. If you had other treatment besides surgery and there are no signs of cancer, then you will be observed by your doctor. He or she will begin follow-up tests and will watch you closely for any signs or symptoms of disease. Next steps If you will receive systemic therapy, see Guide 23 on page 74. For stage III follow-up tests, see Guide 14 on the next page. Guide 14 shows the follow-up tests that are needed after completing primary treatment or adjuvant treatment for stage III regional melanoma. Follow-up tests are used to monitor you after treatment and 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 first (primary) tumor to other sites in the body. Your doctor may suggest more or less frequent follow-up testing based on your risk for recurrence. A complete skin exam by your doctor is recommended every year for life. In addition, you should examine your own skin and lymph nodes on a regular basis. You should also have regular medical check-ups and physical exams. During the physical exam, your doctor will carefully examine your lymph nodes and skin. Imaging tests are recommended to check out specific signs or symptoms of cancer. You may also have imaging tests to screen for cancer recurrence or metastases. Screening means testing to detect a disease when there are no signs or symptoms present. The type and frequency of imaging tests varies based on your risk of cancer recurrence or spread (metastasis). You may have imaging tests for screening every 3 to 12 months. This may include a CT scan of your chest, abdomen, and pelvis; a PET/CT scan; and/or an MRI of your brain.