HemeOnc
Melanoma
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Melanoma
, Cutaneous Malignant Melanoma, CMM
See Also
Ocular Melanoma
Subungual Melanoma
Nevus
Congenital Melanocytic Nevus
Atypical Nevus
Melanoma
Melanoma Risk Factors
Cancer Survivor Care
Epidemiology
Deaths: 7700 per year in United States predicted 2005
Sixth leading cause of death in United States
Accounts for 75% of deaths from
Skin Cancer
s
Incidence
: 59,580 new U.S. cases estimated for 2005
Accounts for only 3-5% of
Skin Cancer
s
Most common cancer in women age 25 to 29 years (and second most common cancer ages 30-35 years)
Increasing
Incidence
Has doubled every 10 years (related to ozone deplete)
One in 74 Americans develop Melanoma yearly
Increasing risk with age
Incidence
in age under 14 years: 0.3%
Incidence
in age under 20 years: 2%
Median age of diagnosis: 57 years old
Incidence
increasing fastest in men over age 65 years
Pathophysiology
Melanocyte
malignant transformation
Risk Factors
See
Melanoma Risk Factors
Precursor Lesions
Lentigo
maligna
Congenital neoplastic nevi
Clark's melanocytic nevi (
Dysplastic Nevus
)
Classification
Precaution: Melanoma is Melanoma (manage all types aggressively)
Melanoma in Situ
Malignant
Melanocyte
s are confined to the
Epidermis
Excision is typically curative with 5 mm margins
Superficial spreading Melanoma (SSM): 70% of Melanoma
More common at age 30-50 years, often on the trunk, and in women often on the legs
Initially brown to black lesions develop blue, red, white color variations
Form irregular, unusual shapes
Initially flat radial growth for months to years and when >2.5 cm vertically grow into
Nodule
s
Nodular Melanoma (NM): 15-20% of Melanoma
More common at age 40-60 years and twice as common in men
No horizontal growth phase and rapid vertical growth over weeks to months
Colors vary from brown or black to red or purple
May appear flesh colored (amelanotic nodular Melanoma) and appear more like
Basal Cell Carcinoma
Most frequently misdiagnosed Melanoma (see differential diagnosis below)
Lentigo
maligna Melanoma (LMM): 5-15% of Melanoma
More common at age 50-80 years, especially with sun-damaged skin
Develops on the face in 90% of cases
Develops from the precursor lesion
Lentigo
maligna (Hutchinson's
Freckle
)
Lentigo
maligna is the in situ form of
Lentigo
maligna Melanoma
Slowly grows over 5 to 15 years prior to shifting into the invasive
Lentigo
maligna Melanoma
Tumors develop in center of
Lentigo
maligna
Typically invades after >5 cm in diameter
Invasion can not be determined by external skin exam
Amelanocytic Melanoma: <5% of Melanoma
Nonpigmented Melanoma
Broad differential diagnosis:
Eczema
, fungal dermatitis,
Basal Cell Carcinoma
,
Squamous Cell Carcinoma
Delay in diagnosis is common and often diagnosed at a more advance stage
Acral Lentiginous Melanoma
(ALM): 2-8% of Melanoma
Represents up to 75% of Melanomas in non-caucasian patients (black or asian ethnicity)
Occurs on acral surfaces
Palms, soles, distal digits (knuckles, fingertips), elbows, knees, ears and mucous membranes
Diagnosis often delayed (presenting at more advanced stage with worse outcomes)
Include foot exam with skin exam, especially in non-caucasian patients
Subungual Melanoma
: Up to 3.5% of Melanoma
Hutchinson Sign is a pigmented longitudinal band under nail plate (
Longitudinal Melanonychia
)
Very aggressive tumor with early metastases even from small lesions
Biopsy of lesion including the nail matrix (typically by dermatology)
Differential Diagnosis
Melanoma look-alikes in general
Seborrheic Keratosis
Irritated nevus
Pigmented
Basal Cell Carcinoma
Lentigo
Blue Nevus
Angiokeratoma
(red to blue vascular lesions)
Trauma
tic
Hematoma
Venous lake (Phlebectases: soft, blue purple lesions on face, especially lips and ears)
Hemangioma
Pigmented
Actinic Keratosis
Nodular Melanoma
Dermatofibroma
(amelanotic)
Basal Cell Cancer
(amelanotic)
Hemangioma
Seborrheic Keratosis
Pyogenic Granuloma
Lab
Histology
Clark's Level
Level 1:
Epidermis
Level 2: Reaches papillary
Dermis
Level 3: Fills papillary
Dermis
Level 4: Enters reticular
Dermis
Level 5: Penetrates subcutaneous fat
Five-year survival related to tumor depth
Survival 99%: Depth < 0.85mm
Survival 80%: Depth 0.85 to 1.69mm
Survival 70%: Depth 1.70 to 3.64mm
Survival 40%: Depth > 3.65mm
Staging (AJCC)
In-Situ
Stage 0
Confined to
Epidermis
(99-100% five and ten year survival)
Localized
Stage IA
Thickness <1 mm and not ulcerated
Survival: 97% five year survival and 95% ten year survival
Stage IB
Thickness 1 mm and ulcerated or 1 to 2 mm and not ulcerated
Survival: 92% five year survival and 86% ten year survival
Stage IIA
Thickness 1 to 2 mm and ulcerated or 2 to 4 mm and not ulcerated
Survival: 81% five year survival and 67% ten year survival
Stage IIB
Thickness 2 to 4 mm and ulcerated or >4 mm and not ulcerated
Survival: 70% five year survival and 57% ten year survival
Stage IIC
Thickness >4 mm and ulcerated
Survival: 53% five year survival and 40% ten year survival
Metastatic
Stage III: Regional node metastases
Stage IIIA - Survival: 78% five year survival and 68% ten year survival
Stage IIIB - Survival: 59% five year survival and 43% ten year survival
Stage IIIC - Survival: 40% five year survival and 24% ten year survival
Stage IV: Distant metastases
Survival: 15-20% five year survival and 10-15% ten year survival
Evaluation
Melanoma metastases
Lymph Node
exam
Full skin exam
Chest XRay
Labs considered above stage IA (and in all cases of Stage III and IV)
Complete Blood Count
(CBC)
Liver Function Test
s (LFT or hepatic panel)
Lactate Dehydrogenase
(LDH)
Advanced imaging (indicated for stage III, IV)
CT Head
, chest and
Abdomen
and/or
PET Scan (eyes to thighs)
Management
Surgical excision
Local excision with clear margins
Melanoma in situ: Margin 0.5 cm
Breslow thickness <2 mm: Margin 1 cm
Breslow thickness >2 mm: Margin 2 cm
Wide margins (>3 cm) no longer recommended
Lymph Node
biopsy indicated if Breslow thickness >1mm
Sentinel Node
biopsy for Breslow thickness 1-4 mm
Mohs Micrographic Surgery
indicated where surgical margins are difficult to detect
Lentigo
maligna
Lentigo
maligna Melanoma
Interferon alfa
-2b (Intron A)
Effective in increasing relapse-free survival
Wheatley (2003) Cancer Treat Rev 29:241-52 [PubMed]
Precautions
Defusing Myths
Hair
y moles do NOT differentiate benign from malignant
Do not prophylacticly biopsy benign appearing moles
Incisional Biopsy
into Melanoma does NOT spread tumor
Prevention
See
Melanoma Prevention
Follow-up Immediately for:
Pruritic nevus
Atypical Nevus
Signs
Frequent skin exams for high risk or Melanoma history
Melanoma in situ (confined to
Epidermis
)
Follow-up every 6 months for 1 year, then
Follow-up yearly
Stage I: Thickness <1 mm and no
Atypical Nevus
syndrome or FHx
Follow-up every 3-4 months for year 1, then
Follow-up every 6 months for year 2, then
Follow-up yearly
Stage II: Thickness >1 mm or Clark's Level IV
CBC, chemistry panel, LDH every 6 months
Consider
Chest XRay
Follow up every 3-4 months for first 3 years, then
Follow up every 6 months for next 2 years, then
Follow-up annually
Stage III: Regional Metastases
CBC, chemistry panel, LDH every 3-6 months
PET Scan and/or CT Scan (per oncology recommendations)
Follow up every 3-6 months for first 3 years, then
Follow up every 4-12 months for next 2 years, then
Follow-up annually
Stage IV: Distant Metastases
Chest XRay
, CBC,
Liver Function Test
s every 3 months
PET Scan and/or CT Scan every 2-4 months for first 5 years and then annually
Follow-up every 3-4 months
Prognosis
See Histology and Staging above
Survival rates are better in women
Relative Risk
of developing a second primary tumor: 10
Second primary cancer develops in 4-8% of Melanoma survivors
Melanoma recurrence may occur more than 10-20 years after the initial Melanoma management
References
Fauci (1998) Harrison's Medicine, 14th ed., McGraw-Hill
Goldstein (2001) Am Fam Physician 63(7): 1359-68 [PubMed]
Houghton (1998) Oncology 12:153-77 [PubMed]
Landis (1999) CA Cancer J Clin 49:8-31 [PubMed]
Rager (2005) Am Fam Physician 72:269-76 [PubMed]
Shenenberger (2012) Am Fam Physician 85(2): 161-8 [PubMed]
Wilbur (2014) Am Fam Physician 91(1):29-36 [PubMed]
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