Locoregional melanoma recurrence
Locoregional recurrence; LR; persistent / recurrent melanoma; isolated regional recurrence
Locoregional recurrence of melanoma includes local recurrence at the scar of a prior wide local excision, satellite / in-transit metastases, and clinically or radiologically detected regional nodal disease. It develops in approximately 5–25% of patients depending on initial stage, anatomical site and adjuvant therapy. Workup confirms the locoregional nature of the disease and excludes distant metastasis; management is multidisciplinary and individualised — surgical clearance is the foundation where feasible, with regional and systemic therapy used in increasingly integrated combinations.
Patterns
- Local recurrence — within or immediately adjacent to the wide-excision scar, attributable to inadequate clearance or aggressive biology.
- Satellite metastasis — ≤ 2 cm from the primary or scar.
- In-transit metastasis — > 2 cm from the primary / scar but proximal to the regional basin — see in-transit metastases.
- Regional nodal recurrence — in a previously negative or previously cleared nodal basin.
- Concurrent multiple patterns possible; restage thoroughly.
Workup
- Detailed clinical examination — entire skin, all lymph-node basins, primary site.
- Photography and mapping of all lesions.
- Biopsy of one or more lesions to confirm recurrence and molecular profile (BRAF V600E/K, NRAS, c-KIT).
- Imaging — CT NCAP, MRI brain, FDG-PET-CT for staging.
- Ultrasound of nodal basin in case of suspected nodal recurrence.
- MDT discussion before any intervention.
Surgical management
- Local recurrence — re-excision with histological clearance; reconstruction often more complex than the primary.
- Nodal recurrence — therapeutic lymphadenectomy in selected patients.
- In-transit / satellite — excision of isolated lesions; staged or focal regional therapy for multifocal.
- SLNB is not repeated for locoregional recurrence — basin treated as known stage III.
- Reconstruction — see reconstruction atlas; aim for tension-free closure that does not preclude further surgery or RT.
Adjuvant and systemic therapy
- After complete surgical clearance of stage III locoregional disease — adjuvant pembrolizumab (TA766), nivolumab (TA684), or dabrafenib + trametinib (TA544) for BRAF V600-mutant disease, per MDT.
- Unresectable locoregional disease — first-line ICI (anti-PD-1 ± anti-CTLA-4) or BRAF / MEK inhibition.
- NHS England URN 2426 commissions neoadjuvant followed by adjuvant pembrolizumab for macroscopic resectable stage III melanoma, age ≥ 12.
- Radiotherapy — for unresectable, palliative, or post-operative high-risk recurrence — see radiotherapy.
Follow-up after recurrence
- More intensive than primary stage III follow-up — many UK MDTs adopt 3-monthly clinic and 3- to 6-monthly imaging for the first 2–3 years.
- Risk of further recurrence remains throughout follow-up; lifelong surveillance is typical for very-high-risk patterns (multiple in-transit, ENE, multi-nodal).
- Functional and psychological support — late lymphoedema, scar revision, ongoing surveillance fatigue.
References
- Sandhu M et al. Locoregional recurrence patterns in melanoma — cohort series. Ann Surg Oncol; 2019.
- NICE NG14. Melanoma: assessment and management. London: NICE; 2015 (last updated 27 July 2022), recommendations 1.8 and 1.9.
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