NCCN Guidelines for Patients® | Melanoma

72 NCCN Guidelines for Patients ® : Melanoma, 2018 5  Treatment guide Metastatic melanoma After a period of observation or systemic therapy, your doctor will repeat imaging tests to show if there are any other metastatic cancer sites. If the imaging tests don’t show any other cancer, then you may have surgery to remove the metastatic tumor. If they do show other cancer, then you will have treatment for widespread metastatic disease. If the tests are negative for other disease after systemic therapy, you may have surgery. The next treatment options depend on whether or not all of the cancer was removed. If all of the cancer was removed by surgery, then you may begin observation or receive nivolumab. If all of the cancer wasn’t removed by surgery, then you will receive treatment for widespread metastatic disease, which is described next. For widespread metastatic disease, the first step is to assess for metastases in your brain. If you have brain metastases, then you will likely receive treatment for the cancer in your brain first to try to prevent other serious medical conditions. This may include surgery and/or radiation therapy. (For more information on treating cancer in the brain and spinal cord, see the NCCN Guidelines for Central Nervous System Cancers . These guidelines are online at www.NCCN.org. They were written for your doctor, so he or she will likely be able to answer your questions about treatment.) Guide 21. Metastatic melanoma treatment Stage Treatment for metastatic disease Next treamtent Limited stage IV (Resectable - cancer can be removed with surgery) ª • Surgery to remove cancer ª • If no evidence of disease, observe or nivolumab • If disease remains, treat as widespread ª • Systemic therapy, then imaging tests to check response or for disease progression ª • If negative for disease, resect and if no disease observe or nivolumab, or if disease remains, treat as widespread • If postive for disease, treat as widespread Widespread stage IV (Unresectable - cancer can’t be removed with surgery) ª • If no cancer in the brain, see next treatment options ª • Systemic therapy • T-VEC injection into tumor • Possible palliative surgery and/or radiation therapy for symptoms • Best supportive or palliative care ª • If cancer in the brain, possible radiation therapy or palliative surgery ± radiation therapy for brain metastases ª

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