NCCN Guidelines for Patients® | Melanoma

71 NCCN Guidelines for Patients ® : Melanoma, 2018 5  Treatment guide Metastatic melanoma Metastatic melanoma This section explains the recommended tests and treatments for melanoma that has spread far away from the first (primary) tumor. This is called metastatic melanoma. Melanoma with distant metastases when first found (diagnosed) is stage IV cancer. However, cancer may come back in a distant site after previous melanoma treatment. This is called a distant metastatic recurrence. The recommended tests and treatments are the same for an initial diagnosis of metastatic melanoma and for metastatic recurrence. Guide 20 shows the tests that are needed for metastatic melanoma. The first step is to confirm the metastatic cancer with a biopsy of one of the distant tumors. An FNA, core, incisional, or excisional biopsy may be used. Your doctor may remove another tissue sample for genetic testing if you’re thinking about entering a clinical trial or getting targeted therapy. A blood test to measure your LDH level is recommended. This test will give information about your prognosis—the likely course or outcome of the disease. Your doctor may also order other blood tests. For example, your doctor may test for BRAF and other genetic changes as well. Imaging tests are recommended for baseline staging and to evaluate specific signs and symptoms. A baseline is a starting point to which future test results are compared. This may include a CT scan of your chest, abdomen, and pelvis; a PET/CT scan; and/or an MRI of your brain. Guide 21 shows the treatment options for metastatic melanoma. The treatment options depend on whether or not all of the cancer can be removed by surgery. Limited metastatic disease is when cancer has spread to only one or a few distant sites. It is resectable, which means it can be treated with surgery. Widespread metastatic disease is when cancer has spread to too many distant sites. It is unresectable, which means it can’t be treated with surgery. For limited metastatic disease, one of the first treatment options is surgery to remove the whole tumor if possible. The next options depend on whether or not disease remains. If there is no evidence of disease, you can begin observation or receive nivolumab. If surgery is not possible, you may receive systemic therapy. Guide 20. Metastatic melanoma tests Stage Tests Stage IV ª • Biopsy (FNA, core, incisional, or excisional) of distant tumor • LDH • Imaging tests for baseline staging and to check out specific signs or symptoms

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