What to do after a melanoma diagnosis
After histological confirmation of melanoma, the next step is not to rush into an isolated procedure. The pathology should be assembled, the stage defined and the treatment sequence planned.
Five decisions that should not be separated
Pathology
Breslow, ulceration, margins and T category.
Stage
Examination, lymph nodes and imaging when indicated.
Surgery
Wide local excision and, when appropriate, SLNB.
Systemic therapy
Adjuvant, neoadjuvant or treatment of active disease.
Surveillance
A written individual follow-up plan.
Step 1. Review the pathology report
A complete pathology report is needed for planning. Breslow thickness, ulceration, margin status and other features required for T classification and subsequent decisions are particularly important. If the material is incomplete, wording is contradictory or the case is complex, review of slides or blocks may be appropriate.
Step 2. Define the clinical stage
Not every patient needs the same investigations. Imaging depends on tumour thickness, ulceration, clinical examination, symptoms and preliminary stage. Higher-risk situations may require imaging to assess regional or distant disease.
If a lymph node is already suspicious
This is not a routine SLNB situation - the suspicious node needs targeted assessment first.
Step 3. Plan wide local excision and SLNB together
Diagnostic excisional biopsy and wide local excision (WLE) have different purposes. Even when the primary lesion was removed with negative margins, invasive melanoma may still require WLE with a clinical margin determined by the pathology.
If sentinel lymph node biopsy (SLNB) is indicated, it is best planned before or at the same time as WLE. This preserves the correct sequence of lymphatic mapping and surgery.
Step 4. Decide whether systemic treatment is relevant
Systemic treatment is not needed for everyone. After complete resection, adjuvant therapy may be discussed when recurrence risk is sufficiently high. In selected resectable stage III melanomas with clinically or radiologically detectable regional disease, systemic treatment before surgery may be considered by a multidisciplinary team. For unresectable or metastatic disease, systemic therapy is a major component of treatment.
BRAF can become part of the next decision
For some patients, BRAF V600 testing can influence treatment options. BRAF status does not replace stage or clinical context.
Step 5. Leave with a written follow-up plan
After the main treatment phase, it should be clear who provides surveillance, how clinical and dermatological review will be organised, whether lymph-node ultrasound or other imaging is needed, and which symptoms should prompt earlier contact. There is no single universal schedule for every stage.
What to bring to a consultation
- the complete pathology report;
- slides and/or paraffin blocks if available;
- the report from the previous excision or operation;
- photos of the original lesion before removal, if available;
- images/files and reports from CT, PET-CT, MRI or ultrasound if already performed;
- a list of comorbidities and regular medications.
What to avoid
Do not plan “another excision”, another lymph-node biopsy or another isolated procedure without considering whether it could affect staging or the sequence of subsequent treatment.
Reviewed sources
This page describes the pathway after diagnosis. It does not replace individual staging or multidisciplinary treatment decisions.