Management of Cutaneous Head and Neck Melanoma

The incidence of melanoma continues to increase at epidemic proportions. Pigmented lesions demonstrating asymmetry, border irregularity, color variation, a diameter greater than 6 mm, and evolving changes should be considered for biopsy. Ultimately the prognostic information from this biopsy guides staging and associated treatment options. The American Joint Committee on Cancer has updated the melanoma staging system. Although it remains founded on the tumor-node-metastasis (TNM) classification, mitotic rate has been removed from the primary tumor staging. Surgery is the standard of care for melanoma, with wide local excision using 0.5- to 2-cm margins based on tumor depth of invasion. Sentinel lymph node biopsy (SLNB) can be considered for patients with localized disease with more than 1 mm depth of invasion or for thinner melanomas in the setting of poor prognostic features. T status and therapeutic neck dissection constitute the standard of care for known regional disease in the absence of distant metastasis. Radiation is an adjuvant therapy for high-risk patients with extracapsular spread or multiple node involvement. Interferon-α2b no longer remains the only agent approved by the U.S. Food and Drug Administration (FDA) for advanced melanoma. Ipilimumab, vemurafenib (for BRAF-mutated tumors), and PD1 inhibitors such as nivolumab and pembrolizumab are approved for stage IV melanoma. They are also being selectively used in the adjuvant setting.