Beruflich Dokumente
Kultur Dokumente
14064 JEADV
GUIDELINES
Abstract
As knowledge continues to develop, regular updates are necessary concerning recommendations for practice. The recom-
mendations for the management of melanoma stages I to III were drawn up in 2005. At the request of the Socie te
Francß aise de Dermatologie, they have now been updated using the methodology for recommendations proposed by the
Haute Autorite de Sante
in France. In practice, the principal recommendations are as follows: for staging, it is recom-
mended that the 7th edition of AJCC be used. The maximum excision margins have been reduced to 2 cm. Regarding
adjuvant therapy, the place of interferon has been reduced and no validated emerging medication has yet been identified.
Radiotherapy may be considered for patients in Stage III at high risk of relapse. The sentinel lymph node technique remains
an option. Initial examination includes routine ultrasound as of Stage II, with other examinations being optional in stages
IIC and III. A shorter strict follow-up period (3 years) is recommended for patients, but with greater emphasis on imaging.
Received: 28 July 2016; Accepted: 31 October 2016
Conflicts of interest
None declared.
Funding Sources
None declared.
JEADV 2017, 31, 594–602 © 2017 European Academy of Dermatology and Venereology
French recommendation in stage I to III melanoma 595
which doubles every 20 years. From 1980 to 2005, for example, This project is also committed to upholding Measure 19 of
the standardized melanoma incidence per 100 000 people rose the 2009–2013 Cancer Plan, aimed at reinforcing treatment
from 2.4 to 7.6 in men and from 3.9 to 8.8 in women. In con- quality for all cancer patients.
trast, the mortality rate rose less quickly in this time period,
remaining quite stable in women. The mortality rate rose from Methodology
0.8 to 1.1 in women and from 0.9 to 1.6 in men during this per- The following methodology was implemented for carrying out
iod, while remaining more or less stable from 1995 to 2005 this update:
(www.invs.sante.fr/surveillance/cancers). One of the explana- • Systematic analysis of the literature corresponding to
tions for this slow progression in mortality, despite the increas- questions identified for each topic requiring an update,
ing incidence, is the efficacy of prevention and early screening as well as consultation of foreign published recommenda-
programmes. There is no doubt that melanomas treated early tions;
display a demonstrably better prognosis than those treated later, • Bibliographical research, as conducted between 1 January
hence the significance of tumour thickness: the principal inde- 2005 and 30 May 2015 in the MEDLINE and Cochrane
pendent prognostic factor. databases.
Presently, we are able to define a standardized treatment of The data were analysed on a factual medicine basis, with arti-
melanoma that would likely offer patients the best quality cles selected according to their methodological quality. In the
guarantee with respect to current scientific data. The circuit of treatment domain, randomized controlled trials and meta-ana-
melanoma patient management, which should include the sys- lyses were prioritized, whereas articles with lower evidence levels
tematic discussion of patient records in multidisciplinary con- were rejected for analysis.
sultation meetings (MCMs), in accordance with the French Oral communication and congress summaries were not con-
cancer plan, must aim to homogenize approaches across the sidered, as these data offer no result verification and thus have
whole of France. weak conclusive value.
Management strategies for Stage I to III melanomas were The project team met on three occasions: 15 May 2013, 10
discussed at the 1995 Consensus Conference of the French October 2013 and 15 January 2014.
National Agency for Health Accreditation and Evaluation,1 The recommendations were labelled following a grade of rec-
when guidelines were established according to the ‘Standard, ommendations according to the French National Authority for
Options, and Recommendations’ methodology of the French Health (HAS) classification:
National Federation of Comprehensive Cancer Centers Evidence level A: established scientific evidence;
(FNCLCC) in 1998.2 Evidence level B: scientific presumption; and
In 2001, a practice survey was conducted by ANAES, the pre- Evidence level C: low evidence level.
cursor to the French National Authority for Health, highlighting When the literature did not provide answers to the questions
the need to update the 1995 recommendations across five topics asked, the recommendation given was labelled ‘expert opinion’.
(resection margins, classification, the role of adjuvant treat-
ments, the role of sentinel node biopsy and update of follow- Topic 1: Classification
up). Finally, in 2005, these two documents were updated by the To simplify communication between teams and homogenize the
partnership of the French Dermatology Society (SFD), the classification criteria, the 7th edition of the AJCC classification
FNCLCC and the French National Cancer Institute (INCa). was elected the most suitable system for providing a practical
They were updated in the following six domains:3 and widely consented tool, given the robustness of the method-
• Classification; ology employed to develop its classification.
• Resection margins; The 7th edition of the AJCC classification has modified the
• Sentinel node biopsy; previous edition as follows:
• Adjuvant treatments; • Clark’s level is no longer used. The mitotic index is consid-
• Initial workup and patient follow-up; ered instead, replacing Clark’s level of invasion in melano-
• Role of molecular biology tests. mas <1 mm in thickness.
Several scientific studies have been published on melanoma • Lymph node micrometastases detected by immunohisto-
since creating the need to further update the data published in chemistry have now been integrated into Group N1.
2005. The goal was to provide physicians managing melanomas
with up-to-date recommendations following dependable data Recommendation
from the literature as closely as possible, in order to offer The 7th edition of the AJCC classification is recom-
patients access to the most recent scientific innovations and mended for melanoma classification.
decrease the disparities in care that are still encountered in dif-
ferent centres across France. This classification is provided in Annex 1 of the appendices.
JEADV 2017, 31, 594–602 © 2017 European Academy of Dermatology and Venereology
596 Guillot et al.
JEADV 2017, 31, 594–602 © 2017 European Academy of Dermatology and Venereology
French recommendation in stage I to III melanoma 597
JEADV 2017, 31, 594–602 © 2017 European Academy of Dermatology and Venereology
598 Guillot et al.
Recommendation
Stages IIIB and IIIC
Imaging is recommended prior to surgery, such as lymph An oncogenetic consultation is recommended in the
node dissection. This examination may enable the detection of following conditions:
lymph node involvement beyond the conventional dissection Presence, in first- or second-degree relatives or in the
space. It is also preferable to perform 18FDG-PET or C-TAP CT same individual, prior to the age of 75 years, of at least
to eliminate any distant metastases synchronous with the lymph two invasive melanomas.
node involvement. Any suspicious distant involvement detected Presence, in the same individual or in relatives, of an
by 18FDG-PET or C-TAP CT, altering the approach to the meta- invasive cutaneous or ocular melanoma, pancreatic can-
static lymph nodes, requires histological confirmation whenever cer, kidney cancer, mesothelioma or central nervous
indicated medically. system tumour.
Recommendation
On initial diagnostic evaluation of stages IIIB and IIIC. Topic 5B: Follow-up
Full clinical examination of the entire integument and Stages IA–IB
lymph nodes. The 5-year risk of recurrence in Stage I varies between 1%
Imaging using 18FGD-PET or C-TAP CT (expert and 7.1% in Stage IA and between 1% and 18% in Stage IB. The
opinion). recurrences are, in descending order of frequency, local or in-
transit cutaneous, lymphatic and distant in nature. Some recur-
Special cases: rences can occur after short or even very long periods, at times
In the event of an adjuvant treatment option being proposed more than 10 years later. Yet, the risk of recurrence after 3 years
to the patient, notably sentinel node biopsy or an adjuvant is <5%.
JEADV 2017, 31, 594–602 © 2017 European Academy of Dermatology and Venereology
French recommendation in stage I to III melanoma 599
JEADV 2017, 31, 594–602 © 2017 European Academy of Dermatology and Venereology
600 Guillot et al.
JEADV 2017, 31, 594–602 © 2017 European Academy of Dermatology and Venereology
French recommendation in stage I to III melanoma 601
JEADV 2017, 31, 594–602 © 2017 European Academy of Dermatology and Venereology
602 Guillot et al.
* Continued
JEADV 2017, 31, 594–602 © 2017 European Academy of Dermatology and Venereology