Melanoma pp 557-581 | Cite as

Imaging Melanoma

  • Richard L. WahlEmail author
Reference work entry


The role of noninvasive imaging in melanoma differs depending on the clinical circumstance. At diagnosis, no or very limited systemic imaging for tumor staging is performed if patients have no clinical evidence of metastatic disease to lymph nodes or systemically. However, imaging is increasingly used to guide radionuclide sentinel lymph node biopsy procedures, especially if complex drainage routes are expected such as in the head and neck where SPECT/CT can be valuable.

Ultrasound can be used to assess and follow regional lymph nodes in patients in whom sentinel node biopsy is not successful or not performed. In higher-risk patients if there is tumor involvement in lymph nodes at sentinel node imaging, or clinically, more extensive whole-body imaging including CT, FDG PET/CT, and MRI of the brain are commonly performed. Surveillance with these methods at regular intervals is recommended by several groups for several years post diagnosis, though guidance varies and is based on the risk of recurrence.

Imaging, especially with PET/CT, is often used to assess suitability for surgical resection. Treatment response assessments by imaging are performed at more frequent intervals related to the timing of the specific therapy. Special attention in imaging patients treated with immune checkpoint inhibitors is necessary. CT, MRI, and PET/CT can have pseudo-progression, where responding tumors can transiently grow in size and metabolic activity, as well as apparent number, before response occurs. A delay of 1–2 months before repeat imaging to confirm progression or response is often needed. Use of imaging in melanoma still requires careful assessment for appropriateness to assure avoidance of overuse and attendant radiation and economic costs. Noninvasive imaging is a crucial part of the management of melanoma at multiple time points across the history of the illness. As new therapies evolve, our understanding of the best imaging methods and timing of imaging will evolve as well.


Imaging PET/CT Sentinel-node FDG surveillance MRI 


  1. Alvarado GC, Papadopoulos NE, Hwu WJ, Bedikian AY, Homsi J, Myers JN, Bronstein Y, Bassett RL, Hwu P, Kim KB (2011) Pelvic computed tomography scans for surveillance in patients with primary melanoma in the head and neck. Melanoma Res 21(2):127–130PubMedCrossRefGoogle Scholar
  2. Baker JJ, Meyers MO, Frank J, Amos KD, Stitzenberg KB, Ollila DW (2014) Routine restaging PET/CT and detection of initial recurrence in sentinel lymph node positive stage III melanoma. Am J Surg 207(4):549–554PubMedCrossRefGoogle Scholar
  3. Balch CM, Gershenwald JE (2014) Clinical value of the sentinel-node biopsy in primary cutaneous melanoma. N Engl J Med 370(7):663–664PubMedCrossRefGoogle Scholar
  4. Beasley GM, Parsons C, Broadwater G, Selim MA, Marzban S, Abernethy AP, Salama AK, Eikman EA, Wong T, Zager JS, Tyler DS (2012) A multicenter prospective evaluation of the clinical utility of F-18 FDG-PET/CT in patients with AJCC stage IIIB or IIIC extremity melanoma. Ann Surg 256(2):350–356PubMedPubMedCentralCrossRefGoogle Scholar
  5. van den Bent MJ, Wefel JS, Schiff D, Taphoorn MJ, Jaeckle K, Junck L, Armstrong T, Choucair A, Waldman AD, Gorlia T, Chamberlain M, Baumert BG, Vogelbaum MA, Macdonald DR, Reardon DA, Wen PY, Chang SM, Jacobs AH (2011) Response assessment in neuro-oncology (a report of the RANO group): assessment of outcome in trials of diffuse low-grade gliomas. Lancet Oncol 12(6):583–593PubMedCrossRefGoogle Scholar
  6. van den Berg NS, Brouwer OR, Schaafsma BE, Matheron HM, Klop WM, Balm AJ, van Tinteren H, Nieweg OE, van Leeuwen FW, Valdes Olmos RA (2015) Multimodal surgical guidance during sentinel node biopsy for melanoma: combined gamma tracing and fluorescence imaging of the sentinel node through use of the hybrid tracer indocyanine green-(99m)Tc-Nanocolloid. Radiology 275(2):521–529PubMedCrossRefGoogle Scholar
  7. Bronstein Y, Ng CS, Hwu P, Hwu WJ (2011) Radiologic manifestations of immune-related adverse events in patients with metastatic melanoma undergoing anti-CTLA-4 antibody therapy. AJR Am J Roentgenol 197(6):W992–W1000PubMedCrossRefGoogle Scholar
  8. Chiou VL, Burotto M (2015) Pseudoprogression and immune-related response in solid tumors. J Clin Oncol 33(31):3541–3543PubMedPubMedCentralCrossRefGoogle Scholar
  9. Cho SY, Lipson EJ, Im HJ, Rowe SP, Gonzalez EM, Blackford A, Chirindel A, Pardoll DM, Topalian SL, Wahl RL (2017) Prediction of response to Immune Checkpoint Inhibitor Therapy Using Early-Time-Point 18F-FDG- PET/CT Imaging in Patients with Advanced Melanoma. J Nucl Med. 58(9):1421–1428PubMedPubMedCentralCrossRefGoogle Scholar
  10. Cordeiro E, Gervais MK, Shah PS, Look Hong NJ, Wright FC (2016) Sentinel lymph node biopsy in thin cutaneous melanoma: a systematic review and meta-analysis. Ann Surg Oncol 23(13):4178–4188PubMedCrossRefGoogle Scholar
  11. Danielsen M, Hojgaard L, Kjaer A, Fischer BM (2013) Positron emission tomography in the follow-up of cutaneous malignant melanoma patients: a systematic review. Am J Nucl Med Mol Imaging 4(1):17–28PubMedPubMedCentralGoogle Scholar
  12. Danielsen M, Kjaer A, Wu M, Martineau L, Nosrati M, Leong SP, Sagebiel RW, Iii JR, Kashani-Sabet M (2016) Prediction of positron emission tomography/computed tomography (PET/CT) positivity in patients with high-risk primary melanoma. Am J Nucl Med Mol Imaging 6(5):277–285PubMedPubMedCentralGoogle Scholar
  13. Eisenhauer EA, Therasse P, Bogaerts J, Schwartz LH, Sargent D, Ford R, Dancey J, Arbuck S, Gwyther S, Mooney M, Rubinstein L, Shankar L, Dodd L, Kaplan R, Lacombe D, Verweij J (2009) New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer 45(2):228–247PubMedPubMedCentralCrossRefGoogle Scholar
  14. Friedman KP, Wahl RL (2004) Clinical use of positron emission tomography in the management of cutaneous melanoma. Semin Nucl Med 34(4):242–253PubMedCrossRefGoogle Scholar
  15. Fuster D, Chiang S, Johnson G, Schuchter LM, Zhuang H, Alavi A (2004) Is 18F-FDG PET more accurate than standard diagnostic procedures in the detection of suspected recurrent melanoma? J Nucl Med 45(8):1323–1327PubMedGoogle Scholar
  16. Gold JS, Jaques DP, Busam KJ, Brady MS, Coit DG (2007) Yield and predictors of radiologic studies for identifying distant metastases in melanoma patients with a positive sentinel lymph node biopsy. Ann Surg Oncol 14(7):2133–2140PubMedCrossRefGoogle Scholar
  17. Gritters LS, Francis IR, Zasadny KR, Wahl RL (1993) Initial assessment of positron emission tomography using 2-fluorine-18-fluoro-2-deoxy-D-glucose in the imaging of malignant melanoma. J Nucl Med 34(9):1420–1427PubMedGoogle Scholar
  18. Gulec SA, Faries MB, Lee CC, Kirgan D, Glass C, Morton DL, Essner R (2003) The role of fluorine-18 deoxyglucose positron emission tomography in the management of patients with metastatic melanoma: impact on surgical decision making. Clin Nucl Med 28(12):961–965PubMedCrossRefGoogle Scholar
  19. Korn JM, Tellez-Diaz A, Bartz-Kurycki M, Gastman B (2014) Indocyanine green SPY elite-assisted sentinel lymph node biopsy in cutaneous melanoma. Plast Reconstr Surg 133(4):914–922PubMedCrossRefGoogle Scholar
  20. Krug B, Crott R, Lonneux M, Baurain JF, Pirson AS, Vander Borght T (2008) Role of PET in the initial staging of cutaneous malignant melanoma: systematic review. Radiology 249(3):836–844PubMedCrossRefGoogle Scholar
  21. Krug B, Crott R, Roch I, Lonneux M, Beguin C, Baurain JF, Pirson AS, Vander Borght T (2010) Cost-effectiveness analysis of FDG PET-CT in the management of pulmonary metastases from malignant melanoma. Acta Oncol 49(2):192–200PubMedCrossRefGoogle Scholar
  22. Leiter U, Buettner PG, Eigentler TK, Forschner A, Meier F, Garbe C (2010) Is detection of melanoma metastasis during surveillance in an early phase of development associated with a survival benefit? Melanoma Res 20(3):240–246PubMedGoogle Scholar
  23. Lopez-Rodriguez E, Garcia-Gomez FJ, Alvarez-Perez RM, Martinez-Castillo R, Borrego-Dorado I, Fernandez-Ortega P, Zulueta-Dorado T (2016) Role of SPECT-CT in sentinel lymph node biopsy in patients diagnosed with head and neck melanoma. Rev Esp Med Nucl Imagen Mol 35(1):22–28PubMedGoogle Scholar
  24. Macfarlane DJ, Sondak V, Johnson T, Wahl RL (1998) Prospective evaluation of 2-[18F]-2-deoxy-D-glucose positron emission tomography in staging of regional lymph nodes in patients with cutaneous malignant melanoma. J Clin Oncol 16(5):1770–1776PubMedCrossRefGoogle Scholar
  25. Madu MF, Wouters MW, van Akkooi AC (2017) Sentinel node biopsy in melanoma: current controversies addressed. Eur J Surg Oncol 43(3):517–533CrossRefGoogle Scholar
  26. McArthur GA, Puzanov I, Amaravadi R, Ribas A, Chapman P, Kim KB, Sosman JA, Lee RJ, Nolop K, Flaherty KT, Callahan J, Hicks RJ (2012) Marked, homogeneous, and early [18F]fluorodeoxyglucose-positron emission tomography responses to vemurafenib in BRAF-mutant advanced melanoma. J Clin Oncol 30(14):1628–1634PubMedPubMedCentralCrossRefGoogle Scholar
  27. Mena E, Taghipour M, Sheikhbahaei S, Mirpour S, Xiao J, Subramaniam RM (2016) 18F-FDG PET/CT and melanoma: value of fourth and subsequent posttherapy follow-up scans for patient management. Clin Nucl Med 41(9):e403–e409PubMedCrossRefGoogle Scholar
  28. Mihaljevic AL, Rieger A, Belloni B, Hein R, Okur A, Scheidhauer K, Schuster T, Friess H, Martignoni ME (2014) Transferring innovative freehand SPECT to the operating room: first experiences with sentinel lymph node biopsy in malignant melanoma. Eur J Surg Oncol 40(1):42–48PubMedCrossRefGoogle Scholar
  29. Morton DL, Thompson JF, Cochran AJ, Mozzillo N, Nieweg OE, Roses DF, Hoekstra HJ, Karakousis CP, Puleo CA, Coventry BJ, Kashani-Sabet M, Smithers BM, Paul E, Kraybill WG, McKinnon JG, Wang HJ, Elashoff R, Faries MB, M. Group (2014) Final trial report of sentinel-node biopsy versus nodal observation in melanoma. N Engl J Med 370(7):599–609PubMedPubMedCentralCrossRefGoogle Scholar
  30. Neuschmelting V, Lockau H, Ntziachristos V, Grimm J, Kircher MF (2016) Lymph node micrometastases and in-transit metastases from melanoma: in vivo detection with multispectral optoacoustic imaging in a mouse model. Radiology 280(1):137–150PubMedPubMedCentralCrossRefGoogle Scholar
  31. Niebling MG, Bastiaannet E, Hoekstra OS, Bonenkamp JJ, Koelemij R, Hoekstra HJ (2013) Outcome of clinical stage III melanoma patients with FDG-PET and whole-body CT added to the diagnostic workup. Ann Surg Oncol 20(9):3098–3105PubMedCrossRefGoogle Scholar
  32. Niebling MG, Pleijhuis RG, Bastiaannet E, Brouwers AH, van Dam GM, Hoekstra HJ (2016) A systematic review and meta-analyses of sentinel lymph node identification in breast cancer and melanoma, a plea for tracer mapping. Eur J Surg Oncol 42(4):466–473PubMedCrossRefGoogle Scholar
  33. Nishino M, Tirumani SH, Ramaiya NH, Hodi FS (2015) Cancer immunotherapy and immune-related response assessment: the role of radiologists in the new arena of cancer treatment. Eur J Radiol 84(7):1259–1268PubMedPubMedCentralCrossRefGoogle Scholar
  34. Okada H, Weller M, Huang R, Finocchiaro G, Gilbert MR, Wick W, Ellingson BM, Hashimoto N, Pollack IF, Brandes AA, Franceschi E, Herold-Mende C, Nayak L, Panigrahy A, Pope WB, Prins R, Sampson JH, Wen PY, Reardon DA (2015) Immunotherapy response assessment in neuro-oncology: a report of the RANO working group. Lancet Oncol 16(15):e534–e542PubMedPubMedCentralCrossRefGoogle Scholar
  35. Patnana M, Bronstein Y, Szklaruk J, Bedi DG, Hwu WJ, Gershenwald JE, Prieto VG, Ng CS (2011) Multimethod imaging, staging, and spectrum of manifestations of metastatic melanoma. Clin Radiol 66(3):224–236PubMedCrossRefGoogle Scholar
  36. Peric B, Zagar I, Novakovic S, Zgajnar J, Hocevar M (2011) Role of serum S100B and PET-CT in follow-up of patients with cutaneous melanoma. BMC Cancer 11:328PubMedPubMedCentralCrossRefGoogle Scholar
  37. Perng P, Marcus C, Subramaniam RM (2015) (18)F-FDG PET/CT and melanoma: staging, immune modulation and mutation-targeted therapy assessment, and prognosis. AJR Am J Roentgenol 205(2):259–270PubMedCrossRefGoogle Scholar
  38. Podlipnik S, Carrera C, Sanchez M, Arguis P, Olondo ML, Vilana R, Rull R, Vidal-Sicart S, Vilalta A, Conill C, Malvehy J, Puig S (2016) Performance of diagnostic tests in an intensive follow-up protocol for patients with American Joint Committee on Cancer (AJCC) stage IIB, IIC, and III localized primary melanoma: a prospective cohort study. J Am Acad Dermatol 75(3):516–524PubMedCrossRefGoogle Scholar
  39. Reinhardt MJ, Joe AY, Jaeger U, Huber A, Matthies A, Bucerius J, Roedel R, Strunk H, Bieber T, Biersack HJ, Tuting T (2006) Diagnostic performance of body dual modality 18F-FDG PET/CT imaging for N- and M-staging of malignant melanoma: experience with 250 consecutive patients. J Clin Oncol 24(7):1178–1187PubMedCrossRefGoogle Scholar
  40. Ren G, Pan Y, Cheng Z (2010) Molecular probes for malignant melanoma imaging. Curr Pharm Biotechnol 11(6):590–602PubMedCrossRefGoogle Scholar
  41. Rohren EM (2015) PET/computed tomography and patient outcomes in melanoma. PET Clin 10(2):243–254PubMedCrossRefGoogle Scholar
  42. Ross MI, Gershenwald JE (2013) Sentinel lymph node biopsy for melanoma: a critical update for dermatologists after two decades of experience. Clin Dermatol 31(3):298–310PubMedCrossRefGoogle Scholar
  43. Rueth NM, Xing Y, Chiang YJ, Cromwell KD, Ross MI, Lee JE, Gershenwald JE, Royal RE, Cormier JN (2014) Is surveillance imaging effective for detecting surgically treatable recurrences in patients with melanoma? A comparative analysis of stage-specific surveillance strategies. Ann Surg 259(6):1215–1222PubMedCrossRefGoogle Scholar
  44. Sachpekidis C, Larribere L, Pan L, Haberkorn U, Dimitrakopoulou-Strauss A, Hassel JC (2015) Predictive value of early 18F-FDG PET/CT studies for treatment response evaluation to ipilimumab in metastatic melanoma: preliminary results of an ongoing study. Eur J Nucl Med Mol Imaging 42(3):386–396PubMedCrossRefGoogle Scholar
  45. Scarsbrook AF, Ganeshan A, Bradley KM (2007) Pearls and pitfalls of radionuclide imaging of the lymphatic system. Part 1: sentinel node lymphoscintigraphy in malignant melanoma. Br J Radiol 80(950):132–139PubMedCrossRefGoogle Scholar
  46. Schroer-Gunther MA, Wolff RF, Westwood ME, Scheibler FJ, Schurmann C, Baumert BG, Sauerland S, Kleijnen J (2012) F-18-fluoro-2-deoxyglucose positron emission tomography (PET) and PET/computed tomography imaging in primary staging of patients with malignant melanoma: a systematic review. Syst Rev 1:62PubMedPubMedCentralCrossRefGoogle Scholar
  47. Singh B, Ezziddin S, Palmedo H, Reinhardt M, Strunk H, Tuting T, Biersack HJ, Ahmadzadehfar H (2008) Preoperative 18F-FDG-PET/CT imaging and sentinel node biopsy in the detection of regional lymph node metastases in malignant melanoma. Melanoma Res 18(5):346–352PubMedCrossRefGoogle Scholar
  48. Smith L, Macneil S (2011) State of the art in non-invasive imaging of cutaneous melanoma. Skin Res Technol 17(3):257–269PubMedCrossRefGoogle Scholar
  49. Sondak VK, King DW, Zager JS, Schneebaum S, Kim J, Leong SP, Faries MB, Averbook BJ, Martinez SR, Puleo CA, Messina JL, Christman L, Wallace AM (2013) Combined analysis of phase III trials evaluating [(9)(9)mTc]tilmanocept and vital blue dye for identification of sentinel lymph nodes in clinically node-negative cutaneous melanoma. Ann Surg Oncol 20(2):680–688PubMedCrossRefGoogle Scholar
  50. Stoffels I, Boy C, Poppel T, Kuhn J, Klotgen K, Dissemond J, Schadendorf D, Klode J (2012) Association between sentinel lymph node excision with or without preoperative SPECT/CT and metastatic node detection and disease-free survival in melanoma. JAMA 308(10):1007–1014PubMedCrossRefGoogle Scholar
  51. Stoffels I, Muller M, Geisel MH, Leyh J, Poppel T, Schadendorf D, Klode J (2014) Cost-effectiveness of preoperative SPECT/CT combined with lymphoscintigraphy vs. lymphoscintigraphy for sentinel lymph node excision in patients with cutaneous malignant melanoma. Eur J Nucl Med Mol Imaging 41(9):1723–1731PubMedCrossRefGoogle Scholar
  52. Stoffels I, Morscher S, Helfrich I, Hillen U, Leyh J, Burton NC, Sardella TC, Claussen J, Poeppel TD, Bachmann HS, Roesch A, Griewank K, Schadendorf D, Gunzer M, Klode J (2015) Metastatic status of sentinel lymph nodes in melanoma determined noninvasively with multispectral optoacoustic imaging. Sci Transl Med 7(317):317ra199PubMedCrossRefGoogle Scholar
  53. Strobel K, Dummer R, Steinert HC, Conzett KB, Schad K, Lago MP, Soyka JD, Veit-Haibach P, Seifert B, Kalff V (2008) Chemotherapy response assessment in stage IV melanoma patients-comparison of 18F-FDG-PET/CT, CT, brain MRI, and tumor marker S-100B. Eur J Nucl Med Mol Imaging 35(10):1786–1795PubMedCrossRefGoogle Scholar
  54. Trotter SC, Sroa N, Winkelmann RR, Olencki T, Bechtel M (2013) A global review of melanoma follow-up guidelines. J Clin Aesthet Dermatol 6(9):18–26PubMedPubMedCentralGoogle Scholar
  55. Uematsu T, Kasami M, Kiyohara Y (2013) B-mode ultrasound imaging, Doppler imaging, and real-time elastography in cutaneous malignant melanoma and lymph node metastases. Healthcare (Basel) 1(1):84–95CrossRefGoogle Scholar
  56. Ulrich J, van Akkooi AJ, Eggermont AM, Voit C (2011) New developments in melanoma: utility of ultrasound imaging (initial staging, follow-up and pre-SLNB). Expert Rev Anticancer Ther 11(11):1693–1701PubMedCrossRefGoogle Scholar
  57. Valdes Olmos RA, Rietbergen DD, Vidal-Sicart S, Manca G, Giammarile F, Mariani G (2014) Contribution of SPECT/CT imaging to radioguided sentinel lymph node biopsy in breast cancer, melanoma, and other solid cancers: from “open and see” to “see and open”. Q J Nucl Med Mol Imaging 58(2):127–139PubMedGoogle Scholar
  58. Veenstra HJ, Vermeeren L, Olmos RA, Nieweg OE (2012) The additional value of lymphatic mapping with routine SPECT/CT in unselected patients with clinically localized melanoma. Ann Surg Oncol 19(3):1018–1023PubMedCrossRefGoogle Scholar
  59. Vermeeren L, Valdes Olmos RA, Klop WM, van der Ploeg IM, Nieweg OE, Balm AJ, van den Brekel MW (2011) SPECT/CT for sentinel lymph node mapping in head and neck melanoma. Head Neck 33(1):1–6PubMedCrossRefGoogle Scholar
  60. Wachsmann JW, Ganti R, Peng F (2017) Immune-mediated disease in ipilimumab immunotherapy of melanoma with FDG PET-CT. Acad Radiol 24(1):111–115PubMedCrossRefGoogle Scholar
  61. Wahl RL, Jacene H, Kasamon Y, Lodge MA (2009) From RECIST to PERCIST: evolving considerations for PET response criteria in solid tumors. J Nucl Med 50(Suppl 1):122S–150SPubMedPubMedCentralCrossRefGoogle Scholar
  62. Wang SQ, Hashemi P (2010) Noninvasive imaging technologies in the diagnosis of melanoma. Semin Cutan Med Surg 29(3):174–184PubMedCrossRefGoogle Scholar
  63. Wolchok JD, Hoos A, O’Day S, Weber JS, Hamid O, Lebbe C, Maio M, Binder M, Bohnsack O, Nichol G, Humphrey R, Hodi FS (2009) Guidelines for the evaluation of immune therapy activity in solid tumors: immune-related response criteria. Clin Cancer Res 15(23):7412–7420PubMedCrossRefGoogle Scholar
  64. Xing Y, Bronstein Y, Ross MI, Askew RL, Lee JE, Gershenwald JE, Royal R, Cormier JN (2011) Contemporary diagnostic imaging modalities for the staging and surveillance of melanoma patients: a meta-analysis. J Natl Cancer Inst 103(2):129–142PubMedPubMedCentralCrossRefGoogle Scholar
  65. Zender C, Guo T, Weng C, Faulhaber P, Rezaee R (2014) Utility of SPECT/CT for periparotid sentinel lymph node mapping in the surgical management of head and neck melanoma. Am J Otolaryngol 35(1):12–18PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Mallinckrodt Institute of RadiologyWashington University School of MedicineSt. LouisUSA

Section editors and affiliations

  • Keith T. Flaherty
    • 1
  • Boris C. Bastian
    • 2
  • Hensin Tsao
    • 3
    • 4
  • F. Stephen Hodi
    • 5
    • 6
  1. 1.Henri and Belinda Termeer Center for Targeted TherapiesMGH Cancer CenterBostonUSA
  2. 2.UCSF Helen Diller Family Comprehensive Cancer CenterSan FranciscoUSA
  3. 3.AuburndaleUSA
  4. 4.Harvard-MIT Health Sciences and TechnologyCambridgeUSA
  5. 5.FraminghamUSA
  6. 6.Department of Medicine, Brigham and Women's HospitalDana-Farber Cancer InstituteBostonUSA

Personalised recommendations