Locoregional management of in-transit metastasis in melanoma: an Ontario Health (Cancer Care Ontario) clinical practice guideline

  • F. C. Wright Department of General Surgery, Sunnybrook Health Sciences Centre/Odette Regional Cancer Center, Toronto, ON
  • S. Kellett Program in Evidence-Based Care, Ontario Health (Cancer Care Ontario), and Department of Oncology, McMaster University, Hamilton, ON
  • N. J. Look Hong Department of General Surgery, Division of Surgical Oncology, Sunnybrook Health Sciences Centre and Department of Surgery, University of Toronto, Toronto, ON
  • A. Y. Sun Department of Radiation Oncology, University Health Network, Princess Margaret Cancer Centre, Toronto, ON
  • T. P. Hanna Department of Oncology, Division of Radiation Oncology, Queen’s University, Kingston, ON
  • C. Nessim Division of General Surgery, The Ottawa Hospital, and Department of Surgery, The University of Ottawa, Ottawa, ON
  • C.A. Giacomantonio QEII Health Sciences Centre, Capital District Health and Departments of Surgery and Pathology, Dalhousie University, Halifax, NS
  • C.F. Temple-Oberle Departments of Oncology and Surgery, University of Calgary, Calgary, AB
  • X. Song Department of Internal Medicine, Division of Medical Oncology, University of Ottawa and The Ottawa Hospital Cancer Centre, Ottawa, ON
  • T.M. Petrella Division of Medical Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, ON
Keywords: In-transit metastasis, melanoma, ITM, practice guideline


Objective The purpose of this guideline is to provide guidance on appropriate management of satellite and in-transit metastases (ITM) from melanoma.


Methods The guideline was developed by the Program in Evidence-Based Care (PEBC) of Ontario Health (Cancer Care Ontario) and the Melanoma Disease Site Group (DSG). Recommendations were drafted by the Working Group based on a systematic review of publications in MEDLINE and Embase. The document underwent patient and caregiver-specific consultation and was circulated to the Melanoma DSG and the PEBC Report Approval Panel for internal review; the revised document underwent external review.



Minimal ITM were defined as lesions in a location with limited spread (generally 1 to 4 lesions); lesions are generally superficial, often clustered together, and surgically resectable. Moderate disease was defined as > 5 lesions covering a wider area or when new in-transit lesions develop rapidly (over weeks). Maximal disease was defined as large-volume disease with multiple (more than 15 to 20) 2-3 cm nodules or subcutaneous or deeper lesions over a wide area.


1. In patients presenting with minimal ITM, complete surgical excision with negative pathological margins is recommended. In addition to complete surgical resection, adjuvant treatment may be considered.

2. In patients presenting with moderate, unresectable ITM consider using the following approach for localized treatment: intralesional interleukin-2 or talimogene laherparepvec as first choice, topical diphenylcyclopropenone as second choice, or radiation therapy as third choice. There is insufficient evidence to recommend intralesional bacille Calmette-Guerin or carbon dioxide laser ablation outside of a research setting.

3. In patients presenting with maximal ITM confined to an extremity, isolated limb perfusion, isolated limb infusion, or systemic therapy may be considered. In extremely select cases, amputation could be considered as a final option in patients without systemic disease after discussion at a multidisciplinary case conference.

4. In cases where local, regional, or surgical treatments for ITM may be ineffective, unable to be performed, or if a patient has systemic metastases at the same time, systemic therapy may be considered.

How to Cite
Wright, F. C., Kellett, S., Look Hong, N. J., Sun, A. Y., Hanna, T. P., Nessim, C., Giacomantonio, C., Temple-Oberle, C., Song, X., & Petrella, T. (2020). Locoregional management of in-transit metastasis in melanoma: an Ontario Health (Cancer Care Ontario) clinical practice guideline. Current Oncology, 27(3). https://doi.org/10.3747/co.27.6523
Practice Guideline