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Melanoma

NICE guideline [NG14] Melanoma: assessment and management. Last updated: Jul 2022.

Disclaimer

This article is based on the NICE NG14 guideline 2015 (July 2022 update), but has been simplified for clarity.

Some standard practices (e.g. excisional biopsy, Breslow thickness) are included even if not explicitly detailed in NICE. Certain sections have been adapted or condensed for educational purposes.

Guidelines

1st line: dermoscopy

Definitive: full-thickness excisional biopsy (avoid incisional biopsy if possible as it will prevent accurate staging)
  • Assess Breslow thickness - single most importnat prognosis predictor

  • Sentinel lymph node biopsy
    • Do not offer in stage IA melanoma
    • Consider if Breslow thickness >1.0mm or 0.8-1.0mm + ulceration / lymphovascular invasion / mitotic index ≥2
  •   Vitamin D level
  • BRAF analysis
    • Do not offer in stage IA / IB (only in stage IIA and onwards)

  T (tumour) N (node) M (metastasis)
Stage 0
  • In situ (i.e. Breslow depth 0 mm)
  • -ve
  • -ve
Stage I
  • IA: Breslow depth <0.8 mm without ulceration
  • IB: Breslow depth <0.8 mm with ulceration / 0.8-1.0 mm +/- ulceration / 1.0-2.0 mm without ulceration
Stage II
  • IIA: Breslow depth 1.0-2.0 mm with ulceration / 2.0-4.0 mm without ulceration
  • IIB: Breslow depth 2.0-4.0 mm with ulceration / >4.0 mm without ulceration
  • IIC: Breslow depth >4.0 mm with ulceration
Stage III
  • Any Breslow depth
  • +ve
Stage IV
  • +ve / -ve
  • +ve
 

Excision margins based on Breslow thickness (not explicitly stated in the 2022 update but in the earlier 2015 version and reflects standard UK surgical practice):
 
Breslow Thickness Recommended Excision Margin
Melanoma in situ (Stage 0) 0.5–1 cm
≤ 1 mm 1 cm
> 1 mm and ≤ 2 mm 1–2 cm
> 2 mm 2 cm

The following sections are based on latest NICE NG14 (Jul 2022 update).
 

1st line: wide local excision with surgical margin of 0.5cm

Consider topical imiquimod + repeat skin biopsy if surgery would lead to unacceptable disfigurement or morbidity.

1st line: wide local excision, surgical margin:
  • Stage I: 1cm
  • Stage II: 2cm

  • Wide local excision for primary tumour
  • Offer adjuvant immunotherapy or BRAF-targeted therapy if mutation +ve
 
  • Consider topical imiquimod to palliate superficial melanoma skin metastases
  • Do not routinely offer lymph node dissection (there are very specific indications)

If unresectable stage III disease: offer systemic therapy (see below)

1st line: systemic therapy
  • Immunotherapy: nivolumab + ipilimumab
  • Targeted therapy (for BRAF V600 +ve): encorafenib + ninimetinib or dabrafenib + trametinib

If immunotherapy and targeted therapy not appropriate: consider chemotherapy with dacarbazine

References

Author: Adams Lau
Reviewer:
Last edited: 15/07/25