DOI: 10.1111/jdv.

14064 JEADV

GUIDELINES

French updated recommendations in Stage I to III

melanoma treatment and management
B. Guillot,1,* S. Dalac,2 M.G. Denis,3 A. Dupuy,4 J.F. Emile,5 A. De La Fouchardiere,6 E. Hindie,7
T. Jouary,8 N. Lassau,9 X. Mirabel,10 S. Piperno Neumann,11 S. De Raucourt,12 R. Vanwijck13
1
Dermatology Department, CHU Montpellier
2
Dermatology Department, CHU Dijon
3
Laboratory of Biochemistry, CHU Nantes
4
Dermatology Department, CHU Rennes
5
Laboratory of Pathology, AP-HP Ambroise Pare
Hospital, Boulogne, France
6
Laboratory of Pathology, Centre Le
on B
erard Lyon
7
Department of Nuclear medicine, CHU Bordeaux
8
Dermatology Department, CH Pau
9
Department of Radiology, Institut Gustave Roussy Villejuif
10
Department of Radiotherapy, Centre Oscar Lambret Lille,
11
Institut Curie, Paris, France
12
1 Avenue du 6 Juin, 1945, 14000 Caen, France
13
Louvain Catholic University, Brussels, Belgium
*Correspondence: B. Guillot. E-mail: b-guillot@chu-montpellier.fr

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.

Introduction cancer.fr)]. While early diagnosed melanomas have a good prog-

Melanoma represents the 13th most common cause of cancer in
women, and the 7th in men. In 2012, 11 176 new cases were
diagnosed in France. In the same year, melanoma was reported
as the cause of 1672 deaths. The 5-year specific survival rate for
melanoma was 85% [the French National Cancer Institute
(INCA) annual report on the situation of cancer 2013 (www.e-
The long version and rationale are accessible on the French Dermatological
Society website: http://www.sfdermato.org/.
They have also been published in the 2016 edition of Annales de Dermatologie
n e
et Ve rologie.
nosis and are typically cured by simple surgery, the evolved
forms, notably metastatic melanomas, have extremely poor
prognoses. The emergence of new molecules and, more signifi-
cantly, targeted therapies and immunotherapy has altered the
treatment landscape, yet without fundamentally impacting prog-
nosis.
At present, melanoma represents a significant public health
concern due to its rapidly climbing incidence. Epidemiological
studies have shown that melanoma has among the highest
growth rates of all tumours in France, in terms of incidence

JEADV 2017, 31, 594–602 © 2017 European Academy of Dermatology and Venereology
French recommendation in stage I to III melanoma
which doubles every 20 years. From 1980 to 2005, for example,
the standardized melanoma incidence per 100 000 people rose
from 2.4 to 7.6 in men and from 3.9 to 8.8 in women. In con-
trast, the mortality rate rose less quickly in this time period,
remaining quite stable in women. The mortality rate rose from
0.8 to 1.1 in women and from 0.9 to 1.6 in men during this per-
iod, while remaining more or less stable from 1995 to 2005
(www.invs.sante.fr/surveillance/cancers). One of the explana-
tions for this slow progression in mortality, despite the increas-
ing incidence, is the efficacy of prevention and early screening
programmes. There is no doubt that melanomas treated early
display a demonstrably better prognosis than those treated later,
hence the significance of tumour thickness: the principal inde-
pendent prognostic factor.
Presently, we are able to define a standardized treatment of
melanoma that would likely offer patients the best quality
guarantee with respect to current scientific data. The circuit of
melanoma patient management, which should include the sys-
tematic discussion of patient records in multidisciplinary con-
sultation meetings (MCMs), in accordance with the French
cancer plan, must aim to homogenize approaches across the
whole of France.
Management strategies for Stage I to III melanomas were
discussed at the 1995 Consensus Conference of the French
National Agency for Health Accreditation and Evaluation,1
when guidelines were established according to the ‘Standard,
Options, and Recommendations’ methodology of the French
National Federation of Comprehensive Cancer Centers
(FNCLCC) in 1998.2
In 2001, a practice survey was conducted by ANAES, the pre-
cursor to the French National Authority for Health, highlighting
the need to update the 1995 recommendations across five topics
(resection margins, classification, the role of adjuvant treat-
ments, the role of sentinel node biopsy and update of follow-
up). Finally, in 2005, these two documents were updated by the
partnership of the French Dermatology Society (SFD), the
FNCLCC and the French National Cancer Institute (INCa).
They were updated in the following six domains:3
• Classification;
• Resection margins;
• Sentinel node biopsy;
• Adjuvant treatments;
• Initial workup and patient follow-up;
• Role of molecular biology tests.
Several scientific studies have been published on melanoma
since creating the need to further update the data published in
2005. The goal was to provide physicians managing melanomas
with up-to-date recommendations following dependable data
from the literature as closely as possible, in order to offer
patients access to the most recent scientific innovations and
decrease the disparities in care that are still encountered in dif-
ferent centres across France.
JEADV 2017, 31, 594–602
595
This project is also committed to upholding Measure 19 of
the 2009–2013 Cancer Plan, aimed at reinforcing treatment
quality for all cancer patients.
Methodology
The following methodology was implemented for carrying out
this update:
• Systematic analysis of the literature corresponding to
questions identified for each topic requiring an update,
as well as consultation of foreign published recommenda-
tions;
• Bibliographical research, as conducted between 1 January
2005 and 30 May 2015 in the MEDLINE and Cochrane
databases.
The data were analysed on a factual medicine basis, with arti-
cles selected according to their methodological quality. In the
treatment domain, randomized controlled trials and meta-ana-
lyses were prioritized, whereas articles with lower evidence levels
were rejected for analysis.
Oral communication and congress summaries were not con-
sidered, as these data offer no result verification and thus have
weak conclusive value.
The project team met on three occasions: 15 May 2013, 10
October 2013 and 15 January 2014.
The recommendations were labelled following a grade of rec-
ommendations according to the French National Authority for
Health (HAS) classification:
Evidence level A: established scientific evidence;
Evidence level B: scientific presumption; and
Evidence level C: low evidence level.
When the literature did not provide answers to the questions
asked, the recommendation given was labelled ‘expert opinion’.
Topic 1: Classification
To simplify communication between teams and homogenize the
classification criteria, the 7th edition of the AJCC classification
was elected the most suitable system for providing a practical
and widely consented tool, given the robustness of the method-
ology employed to develop its classification.
The 7th edition of the AJCC classification has modified the
previous edition as follows:
• Clark’s level is no longer used. The mitotic index is consid-
ered instead, replacing Clark’s level of invasion in melano-
mas <1 mm in thickness.
• Lymph node micrometastases detected by immunohisto-
chemistry have now been integrated into Group N1.
Recommendation
The 7th edition of the AJCC classification is recom-
mended for melanoma classification.
This classification is provided in Annex 1 of the appendices.
© 2017 European Academy of Dermatology and Venereology
596
Topic 2: Resection margins
The new data taken from one randomized study and three
meta-analyses do not clarify whether a large resection margin
should be given priority over a more conservative treatment.
Furthermore, all of the recommendations we consulted,
except those from Great Britain, advise that no margins
should exceed 2 cm.
Recommendation
Lateral resection margins performed for primitive
utaneous melanoma should be adapted to the depth of
the melanoma’s infiltration, following the guidelines
below:
In situ melanoma: 0.5 cm margin
0.1–1-mm melanoma: 1 cm margin
1.1–2-mm melanoma: 1–2 cm margin
>2 mm melanoma: 2 cm margin
(Recommendation Grade B)
No robust data were found regarding optimal resection
depth, leading the project team (PT) to recommend
resection down to the fascia while conserving it return
(Recommendation Grade C).
For cases of Dubreuilh melanoma or lentigo maligna
melanoma
As regards surgical resection of Dubreuilh melanomas, the PT
recommends maintaining the 2005 guidelines for in situ len-
tigo maligna type. The data on imiquimod, with no market-
ing authorization in this indication, and on radiotherapy are
not conclusive enough to provide concrete guidelines on their
use in daily practice. However, in very rare cases of inopera-
ble melanoma, preferably in the setting of clinical trials,
radiotherapy or imiquimod can be considered on a case-by-
case basis.
Recommendation
For Dubreuilh melanomas, a 1 cm margin is recom-
mended. When this is not possible, for anatomical or
functional reasons, a 0.5 cm margin is acceptable, pro-
vided there is strict histological monitoring of the bor-
ders, namely using Mohs surgery or an equivalent
surgical technique with extemporaneous border moni-
toring, or even a two-stage surgery (expert opinion).
In the very rare cases of inoperable melanoma, radio-
therapy or imiquimod (without marketing authorization)
may be discussed in an MCM (expert opinion).
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Guillot et al.
Topic 3: Sentinel lymph node analysis
The literature findings on this topic essentially centre on the
intermediate and definitive results of the MSLT1 study.
The sentinel node biopsy technique enables precise stratifica-
tion of melanomas, constituting a strong independent prognos-
tic factor. However, this procedure has not proven beneficial
regarding overall survival. Consequently, it cannot be considered
as the standard. It can be proposed for melanomas >1 mm thick,
provided the patient is aware of the lack of therapeutic benefit. It
should be performed in adequately experienced centres.
Recommendation
Sentinel lymph node biopsy is an option in melanomas
>1 mm in size. If performed, it should be carried out in
a centre with sufficient expertise in this technique.
It is not recommended in melanomas <1 mm in size
(Recommendation Grade A).
This technique can also be proposed in clinical trial
settings, notably as an adjuvant treatment (expert
return opinion).
Role of lymph node dissection
For cases where no sentinel node biopsy can be performed, pub-
lished data on systematic lymph node dissection have not been
expanded since the last recommendations in 2005. In this con-
text, those past recommendations are still to be followed.
Our bibliographical research of data pertaining to cases where
sentinel node biopsy is performed has not provided determining
evidence on whether the discovery of a positive sentinel node
means that immediate dissection is necessary. Until the MSLT2
study data are published, it is impossible to outline a well-sup-
ported approach. In France, the most common approach in
cases where a biopsy reveals positive lymph nodes is to propose
immediate lymph node dissection, yet this is not based on sup-
porting evidence. The MSLT2 study should soon provide
answers to this issue.
Recommendation
In Stage I to II melanomas with no sentinel node biopsy
performed, systematic lymph node dissection is not
recommended (Evidence Level A).
For cases with additional biopsy performed, there is
currently no supporting evidence for prioritizing dissec-
tion either immediately after or on clinical relapse. The
project team recommends maintaining the most com-
monly employed approach of immediate dissection
(expert opinion).
© 2017 European Academy of Dermatology and Venereology
French recommendation in stage I to III melanoma
Topic 4: Adjuvant treatments
Medical treatments
Currently, only interferon is discussed as potential adjuvant
treatment, yet its impact on mortality is difficult to interpret.
This can be seen in the wide disparity in foreign recommenda-
tions, labelling interferon as anything from ‘not recommended’
to ‘recommended’.
The other medical treatments analysed (gangliosides, ipili-
mumab or bevacizumab) have not provided proven evidence of
efficacy in terms of overall survival and can thus not be recom-
mended. Moreover, none have marketing authorization for the
melanoma indication.
Recommendation
Medical adjuvant treatments:
1 Given the significant progress made in disease con-
trol by a potentially effective adjuvant treatment, it is
justified to encourage patients to participate in high-
quality therapeutic trials. Randomized studies com-
prising an observation arm remain scientifically
acceptable tools for testing new adjuvant treatments.
2 Monitoring without adjuvant treatment is an option.
3 The only systematic adjuvant treatment currently
under discussion is that of low-dose interferon treat-
ment, in its non-pegylated form.
4 ‘High-dose’ interferon courses are not recom-
mended.
(Recommendation Grade B)
Adjuvant radiotherapy of the lymph nodes following
positive dissection
Three studies were considered following the literature analysis
conducted for the 2005 recommendations: two retrospective
studies and one multicentre randomized controlled study.
Following N+ dissection, patients at high risk of local recur-
rence in the affected lymph nodes can benefit from adjuvant
irradiation, proven to reduce this local relapse risk without
affecting overall survival.
Recommendation
The role of radiotherapy:
Adjuvant radiotherapy following N+ dissection is an
option to be discussed at MCMs for patients at high
risk of local recurrence (presence of capsular rupture,
>3 positive lymph nodes or nodes >3 cm in diameter)
without distant metastases, who cannot be included in
adjuvant treatment studies.
(Dose: 48–50 Gy in standard fractionation)
(Recommendation Grade B)
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597
Isolated-limb perfusion
Three articles on this topic were selected as follows: two sys-
tematic reviews of randomized and observational trials and
one randomized controlled trial comparing the use of mel-
phalan alone vs. melphalan plus TNF-alpha. These studies
focused, however, primarily on inoperable Stage III or IV
melanomas. They were only of average quality, providing no
proven evidence of effects on overall survival, and most often
compared different technical approaches, mostly with response
rates as their only objective.
Recommendation
The role of isolated-limb perfusion:
Based on our current understanding, chemotherapy
on isolated limbs is not recommended for locally
advanced or recurring melanomas on the limbs
(Recommendation Grade C). In certain, highly
specific cases, this technique may be discussed in
MCMs.
Topic 5: Initial workup and follow-up of melanoma
patients undergoing surgery
Topic 5A: Initial workup by imaging
Stages IA–IB
All the recommendations are in agreement that systematic
radiological examinations should not be proposed in the ini-
tial workup. This workup should thus be essentially clinical in
nature, comprising a full clinical examination covering the
entire integument and lymph nodes. Time should be allowed
to clearly explain the objectives to the patient (therapeutic
education, sun protection, self-monitoring) when giving the
diagnosis.
Recommendation
On initial diagnostic evaluation for stages IA and IB:
Full clinical examination, particularly of the whole
integument and lymph nodes.
No systematic additional examination is recommended
(expert opinion).
Stages IIA and IIB
Well-conducted studies have demonstrated that ultrasound
offers better sensitivity compared to clinical examination alone
in detecting lymph node metastases. On the other hand, no
study has yet demonstrated a direct benefit for the patient in
terms of overall survival.
© 2017 European Academy of Dermatology and Venereology
598
Recommendation
On initial diagnostic evaluation of stages IIA and IIB:
Full clinical examination, notably covering the entire
integument and lymph nodes.
Ultrasound imaging of the lymphatic drainage system.
(expert opinion)
Stages IIC and IIIA
There are several prospective and retrospective studies on the
value of imaging in this context, with contradictory results. Per-
forming imaging [computed tomography (CT) or 18FDG-posi-
tron emission tomodensitometry (PET) scan] is an option.
Although 18FDG-PET appears more efficient than classic CT, no
official recommendation of one over the other can be made due
to the highly variable accessibility of these devices across the
country.
Recommendation
On initial diagnostic evaluation in stages IIC and IIIA:
Full clinical examination, notably of the whole integu-
ment and lymph nodes.
Ultrasound imaging of the lymphatic drainage system
for Stage IIC.
Optional: imaging by means of cerebral and tho-
racic–abdominal–pelvic (C-TAP) CT or 18FDG-PET,
especially if the sentinel node biopsy is proposed
in Stage IIC or prior to dissection in Stage IIIA
(expert opinion).
Stages IIIB and IIIC
Imaging is recommended prior to surgery, such as lymph
node dissection. This examination may enable the detection of
lymph node involvement beyond the conventional dissection
space. It is also preferable to perform 18FDG-PET or C-TAP CT
to eliminate any distant metastases synchronous with the lymph
node involvement. Any suspicious distant involvement detected
by 18FDG-PET or C-TAP CT, altering the approach to the meta-
static lymph nodes, requires histological confirmation whenever
indicated medically.
Recommendation
On initial diagnostic evaluation of stages IIIB and IIIC.
Full clinical examination of the entire integument and
lymph nodes.
Imaging using 18FGD-PET or C-TAP CT (expert
opinion).
Special cases:
In the event of an adjuvant treatment option being proposed
to the patient, notably sentinel node biopsy or an adjuvant
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Guillot et al.
course of low-dose interferon, performing prior imaging is justi-
fied in order to verify that the disease is not more developed
than presumed.
Recommendation
In the event of a sentinel node biopsy or adjuvant treat-
ment of low-dose interferon being proposed to the
patient, an initial imaging workup should be discussed
separately for each case (expert opinion).
Immunohistochemistry prognostic markers of melanoma
Recommendation
Recommendation
There is no indication for systematically performing
immunohistochemistry prognostic markers for stages I-
III, according to current knowledge (Recommendation
Grade A).
Role of oncogenetic consultation in melanoma
management
French recommendations on this topic have recently been pub-
lished.4 Consequently, our project team has not addressed this
issue, nor repeated the literature analysis. It should be noted that
the genes currently recognized as being involved in melanoma
occurrence are those associated with high risk (CDKN2A, CDK4
and BAP1) and intermediate susceptibility (MC1R and MITF).
Recommendation
An oncogenetic consultation is recommended in the
following conditions:
Presence, in first- or second-degree relatives or in the
same individual, prior to the age of 75 years, of at least
two invasive melanomas.
Presence, in the same individual or in relatives, of an
invasive cutaneous or ocular melanoma, pancreatic can-
cer, kidney cancer, mesothelioma or central nervous
system tumour.
Topic 5B: Follow-up
Stages IA–IB
The 5-year risk of recurrence in Stage I varies between 1%
and 7.1% in Stage IA and between 1% and 18% in Stage IB. The
recurrences are, in descending order of frequency, local or in-
transit cutaneous, lymphatic and distant in nature. Some recur-
rences can occur after short or even very long periods, at times
more than 10 years later. Yet, the risk of recurrence after 3 years
is <5%.
© 2017 European Academy of Dermatology and Venereology
French recommendation in stage I to III melanoma
Recommendation
Follow-up of Stage IA and IB melanomas.
Full clinical follow-up (notably including the entire
integument and lymph nodes) alone, consisting of two
consultations per year for 3 years, then one annually
for life.
Educate patients about self-screening for new melano-
mas and self-detection of potential recurrences.
Remind patients of sun protection advice.
There is no indication for paraclinical follow-up examina-
tions for this stage of the disease (Recommendation
Grade C).
Stages IIA–IIB
The 5-year risk of recurrence varies from 22% to 40%. The
majority of recurrences manifest within 3 years.
Recommendation
Follow-up of Stage IIA and IIB melanomas.
Full clinical follow-up, notably including the entire integu-
ment and lymph nodes, consisting of two to four consul-
tations per year for 3 years, then one annually for life.
Educate patients on self-screening for new melanomas
and self-detection of potential recurrences.
Remind patients of sun protection advice
(Recommendation Grade C).
Ultrasound imaging of the lymphatic drainage system
every 3–6 months for 3 years return (Recommendation
Grade C).
There is no indication for other imaging unless called
for due to clinical findings.
Stage IIC–IIIA
The 5-year recurrence risk varies from 35% to 45%.
Recommendation
Follow-up of Stage IIC and IIA melanomas.
Full clinical follow-up, notably including the entire
integument and lymph nodes, with four consultations
per year for 3 years, two per year in years 4 and 5, then
one annually for life.
Educate the patient about self-screening of new mela-
nomas and self-detection of potential recurrences.
Remind the patient of sun protection advice.
(Recommendation Grade C).
Ultrasound imaging of the lymphatic drainage system
every 3–6 months (Recommendation Grade C)
Optional: other imaging examinations, C-TAP CT or
18
FDG PET once a year for 3 years.
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599
Stage IIIB–IIIC
The 5-year recurrence risk varies from 42% to 51% in Stage
IIIB and from 55% to 80% in Stage IIIC.
In this patient population, the majority of detectable metas-
tases manifest within 3 years, with less than 5% recurrence after
36 months.
The majority of recurrences manifest in the first year, then the
risk progressively decreases to <5% after 3 years.
Recommendation
Follow-up of Stage IIIB and IIIC melanomas
Full clinical follow-up, notably including the entire
integument and lymph nodes, consisting of four con-
sultations per year for 3 years, two per year in years 4
and 5, then one yearly.
Educate patients about self-screening of new melano-
mas and self-detection of potential recurrences
Remind patients about sun protection advice.
(Recommendation Grade C).
This clinical follow-up will be adapted for cases involv-
ing adjuvant treatment.
Ultrasound imaging of the lymphatic drainage system
every 3 to 6 months during 3 years return
(Recommendation Grade C).
Additional imaging by means of C-TAP CT or 18FDG-
PET should be proposed to the patient every 6 months
for 3 years (expert opinion).
Role of dermoscopy in the follow-up of Stage I to III
patients
This issue was addressed in the 2007 HAS recommendations and
has not specifically been analysed in the literature since. The full
text can be found on http://www.has-sante.fr under DERMA-
TOSCOPIE [DERMOSCOPIE] POUR SURVEILLANCE
CUTANEE  (in French).
Here is a reminder of the HAS project team’s conclusions:
‘Given the significance of early diagnosis of melanoma and
the promising results of low-evidence level studies published,
the expected service of dermoscopic follow-up is considered suf-
ficient when applying the indications and conditions defined by
HAS’.
‘The recognized indications are diseases at high risk of mela-
noma’.
Recommendation
Dermoscopy is indicated for the follow-up of melanoma
patients, regardless of which stage. How often it should
be performed cannot be defined (Recommendation
Grade B).
© 2017 European Academy of Dermatology and Venereology
600
Role of biological examinations and identification of
progression markers in the follow-up of patients
presenting with Stage I to III cutaneous melanoma
Although lactic acid dehydrogenase (LDH) and S100
calcium-binding protein b (PS100) serum levels are likely
disease prognosticators, treatment in daily practice is typi-
cally not adapted according to the determined levels in
stages I to III.
Recommendation
There is no indication for systematic measurement of
LDH or PS100 serum levels in the initial diagnosis or
follow-up of Stage I to III melanomas (Evidence
Level B).
The exact role these markers play in Stage III requires
additional prospective studies (expert opinion).
Topic 6: The role of molecular biology
examinations (genotyping the tumour)
Given the results achieved using targeted therapies in managing
metastatic melanoma, it is crucial to be able to identify and sys-
tematically benefit from the BRAF status of patients. There is
currently no literature data defining the optimal time to perform
this assessment. However, in order to not delay treatment initia-
tion, and considering the risks of recurrence associated with each
stage of disease, the project team considers it reasonable to
screen for V600 BRAF mutation from Stage IIC onwards, and
crucial in Stage III.
The literature data offer contradictory information on intra-
individual discrepancies in metastatic sites. Nevertheless, geno-
typing results from the primary tumour or dissected lymph
nodes can reasonably be used, especially given that not all vis-
ceral metastases are always accessible for biopsy.
In the current absence of any treatment with market autho-
rization for other mutations, detection of NRAS and cKIT muta-
tions, along with ALK rearrangements, remains a clinical
research area to be further investigated.
Recommendation
There is no indication for screening for BRAF mutation
in primitive melanomas at low risk of recurrence.
For melanomas with high recurrence risk (Stage IIC),
mutation screening may be proposed (expert opinion).
Identification of mutational status is crucial in Stage IV
(Level A). This can be performed by means of genotyp-
ing on the biopsy of an accessible metastatic node or,
lacking that option, of dissected nodes or the primitive
tumour, if these are the only available tissues.
JEADV 2017, 31, 594–602
Guillot et al.
Specificities of French recommendations
compared with other European guidelines in
Stage I to III melanoma
When compared with other European guidelines mainly issued
by the British Association of Dermatologists recommendations
(BAD)5, German Dermatology Society6, Swiss Guidelines7, the
European School of Medical Oncology (ESMO)9 or proposed by
a taskforce of experts from the European Dermatological Forum
(EDF), the European Association of Dermato-Oncology
(EADO) and the European Organization of Research and Treat-
ment of Cancer (EORTC)8, French recommendations in Stage
I–III melanoma care display some specific features.
All previously issued guidelines use AJCC classification and
recommended excision margins are very similar apart from BAD
guidelines that propose a margin of 2–3 cm for 1 mm- to 4-mm-
thick melanoma and 3 cm for melanoma thicker than 4 mm.
The implementation of sentinel lymph node dissection (SLND)
procedure is controversial, and its specific interest is diversely
appreciated among guidelines; French recommendations consider
that SLND should be only optional as overall survival did not
appear to be substantially modified whatsoever by this procedure
in large clinical trials. By contrast, other European guidelines state
that this technique should be routinely proposed to all patients
with melanoma thicker than 1 mm but also for thinner mela-
noma when other risk factors such as ulceration are present.
Adjuvant treatment with interferon after tumour removal of
high-risk melanoma is cautiously tackled in all current guideli-
nes due to an ambiguous efficacy/tolerance balance that does
not appear as really favourable for this molecule.
As to initial staging and follow-up, all guidelines emphasize
the importance of clinical examination. French guidelines are
less dense than EDF recommendations and favour clinical fol-
low-up along with ultrasound examination of regional lymph
nodes in Stage II melanoma, whereas CT scan or 18 FDG scan,
only optional in Stage II, is clearly recommended in Stage III for
all patients. Conversely, BAD guidelines do not routinely recom-
mend any additional investigation in asymptomatic patients
with primary melanoma.
Peripheral blood dosage of PS 100 is not recommended by
French guidelines but is proposed in routine by EDF.
Accordingly, a number of differences do exist between the dif-
ferent national or international guidelines proposed throughout
Europe in this setting especially in domains where evidence-
based data are scarce or lacking. These discrepancies perhaps
reflect differences in daily practice-based management options
between countries and are likely to result from divergent expert
opinions more than evidence-based decisions.
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melanoma. Swiss Med Wkly 2011; 141: w13320.
8 Garbe C, Peris K, Hauschild A et al. Diagnosis and treatment of 0 In situ N0 M0
melanoma. European consensus-based interdisciplinary guideline– IA T1a
Update 2012. Eur J Cancer 2012; 48: 2375–2390. IB T1b
9 Dummer R, Hauschild A, Guggenheim M, Keilhoz U, Pentheroudakis G, T2a
on behalf of the ESMO Guidelines Working group. Cutaneous IIA T2b
melanoma: ESMO Clinical Practice Guidelines for diagnosis, treatment T3a
and follow-up. Ann Oncol 2012; 23: vii87–vii91.
IIB T3b
10 A complete bibliography is available at: Guillot B et al. Actualisation des
T4a
recommandations pour la pris en charge du m
elanome stade I a III. Ann
Dermatol Venereol 2016; 143: 629–652. IIC T4b
IIIA All Ts but not Micrometastases M0
Annex 1: 7th edition of the AJCC classification ulcerated (T1 – 4a) (N1a or N2a)
IIIB All ulcerated Ts (T1 – 4b) Micrometastases
All Ts but not (N1a or N2a)
Primary tumour ulcerated (T1 – 4 a) N1b or N2b or N2c
T classification "Breslow Ulcer/mitosis IIIC All ulcerated N1b or N2b or N2c
thickness in mm Ts (T1 – 4b) N3
T1 ≤1 mm a: without ulcer and All Ts
mitoses <1/mm² IV All Ts All Ns M1
b: with ulcer and/or
mitoses ≥1/mm²
T2 1.01–2 mm a: without ulcer
b: with ulcer
Annex 2: Reading team member
T3 2.01–4 mm a: without ulcer
b: with ulcer Members of the reading team
T4 >4.01 mm a: without ulcer Francßois Aubin Oncodermatologist Besancßon
b: with ulcer
Philippe Beaulieu Dermatologist Pontoise
Blandine Boru Radiologist Boulogne

phanie Catala
Ste Oncologist Perpignan
Regional lymph nodes
Philippe Celerier Oncodermatologist La Rochelle
N classification Number of metastatic Lymph node Guillaume Chaby Dermatologist Amiens
lymph nodes metastatic mass
Patrick Combemale Oncodermatologist Lyon
N1 1 lymph node a: micrometastasis
Didier Cupissol Oncologist Montpellier
b: macrometastasis

phane Dalle
Ste Oncodermatologist Lyon
N2 2–3 lymph nodes a: micrometastasis
Caroline Dutriaux Oncodermatologist Bordeaux
b: macrometastasis
Eric Frouin Anatomopathologist Poitiers
c: satellite in-transit
metastasis(es) without Dimitri Gangloff Surgeon Toulouse
metastatic lymph node Ignacio Garrido Surgeon Toulouse
N3 ≥4 lymph nodes or Lionel Geoffrois Oncologist Nancy
conglomerate Francesco Giammarile Nuclear physician Lyon
lymphadenopathy or
Florence Granel-Brocard Oncodermatologist Nancy
In-transit/satellite
Florent Grange Oncodermatologist Reims
metastasis (es) with
metastatic lymph node Jean Louis Grolleau Plastic surgeon Toulouse

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602 Guillot et al.

* Continued

Members of the reading team

Philippe Henry General practitioner Royan

raldine Jeudy
Ge Oncodermatologist Dijon
Jean Philippe Lacour Oncodermatologist Nice

leste Lebbe
Ce Oncodermatologist Paris
Marie The
re
se Leccia Oncodermatologist Grenoble
Candice Lesage Oncodermatologist Montpellier
Thierry Lesimple Oncologist Rennes
Laurent Machet Oncodermatologist Tours
Sandrine Mansard Oncodermatologist Clermont Ferrand
Nicolas Meyer Oncodermatologist Toulouse
Laurent Mortier Oncodermatologist Lille
Anne Mourregot Surgeon Montpellier
Sylvie Negrier Oncologist Lyon
Marie Penicaud General practitioner Aubervilliers
€lle Quereux
Gae Oncodermatologist Nantes
Marie Aleth Richard Oncodermatologist Marseille
Philippe Saiag Oncodermatologist Boulogne

ro
Je ^me Solassol Molecular biologist Montpellier
Viet-Thi Tran General practitioner Paris
Pierre Vereecken Oncodermatologist Bruxelles

JEADV 2017, 31, 594–602 © 2017 European Academy of Dermatology and Venereology