Dermatology Book

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Melanoma

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

melanoma (C0025202)

Definition (MEDLINEPLUS)

Melanoma is the most serious type of skin cancer. Often the first sign of melanoma is a change in the size, shape, color, or feel of a mole. Most melanomas have a black or black-blue area. Melanoma may also appear as a new mole. It may be black, abnormal, or "ugly looking."

Thinking of "ABCDE" can help you remember what to watch for:

  • Asymmetry - the shape of one half does not match the other
  • Border - the edges are ragged, blurred or irregular
  • Color - the color is uneven and may include shades of black, brown and tan
  • Diameter - there is a change in size, usually an increase
  • Evolving - the mole has changed over the past few weeks or months

Surgery is the first treatment of all stages of melanoma. Other treatments include chemotherapy and radiation, biologic, and targeted therapies. Biologic therapy boosts your body's own ability to fight cancer. Targeted therapy uses substances that attack cancer cells without harming normal cells.

NIH: National Cancer Institute

Definition (NCI) A malignant, usually aggressive tumor composed of atypical, neoplastic melanocytes. Most often, melanomas arise in the skin (cutaneous melanomas) and include the following histologic subtypes: superficial spreading melanoma, nodular melanoma, acral lentiginous melanoma, and lentigo maligna melanoma. Cutaneous melanomas may arise from acquired or congenital melanocytic or dysplastic nevi. Melanomas may also arise in other anatomic sites including the gastrointestinal system, eye, urinary tract, and reproductive system. Melanomas frequently metastasize to lymph nodes, liver, lungs, and brain.
Definition (NCI_NCI-GLOSS) A form of cancer that begins in melanocytes (cells that make the pigment melanin). It may begin in a mole (skin melanoma), but can also begin in other pigmented tissues, such as in the eye or in the intestines.
Definition (NCI_CDISC) A malignant neoplasm composed of melanocytes.
Definition (MSH) A malignant neoplasm derived from cells that are capable of forming melanin, which may occur in the skin of any part of the body, in the eye, or, rarely, in the mucous membranes of the genitalia, anus, oral cavity, or other sites. It occurs mostly in adults and may originate de novo or from a pigmented nevus or malignant lentigo. Melanomas frequently metastasize widely, and the regional lymph nodes, liver, lungs, and brain are likely to be involved. The incidence of malignant skin melanomas is rising rapidly in all parts of the world. (Stedman, 25th ed; from Rook et al., Textbook of Dermatology, 4th ed, p2445)
Definition (CSP) malignant neoplasm derived from cells that are capable of forming melanin, which may occur in the skin of any part of the body, in the eye, or, rarely, in the mucous membranes of the genitalia, anus, oral cavity, or other sites; occurring mostly in adults and may originate de novo or from a pigmented nevus or malignant lentigo; frequently metastasize widely, and the regional lymph nodes, liver, lungs, and brain are likely to be involved.
Concepts Neoplastic Process (T191)
MSH D008545
ICD10 M8720/3
SnomedCT 2092003, 154501005, 189749008, 269503007, 269577007, 309331000009104, 372244006
LNC LA14279-6
English Malignant Melanoma, Melanoma, Melanomas, MELANOMA MALIGNANT, Malignant Melanomas, Melanoma, Malignant, Melanomas, Malignant, Melanoma malignant, [M]Malignant melanoma NOS, Malignant melanoma NOS, Malignant melanoma, no ICD-O subtype, Melanoma [Disease/Finding], malignant melanomas, melanosarcoma, melanoma syndrome, nevocarcinoma, cutaneous melanoma, melanomas, melanocarcinoma, melanoma malignant, Melanoma - malignant, [M]Naevocarcinoma, [M]Melanoma NOS, [M]Melanosarcoma NOS, [M]Melanocarcinoma, [M]Malignant melanoma NOS (morphologic abnormality), [M]Malignant melanoma NOS or melanocarcinoma or melanoma NOS (disorder), [M]Malignant melanoma NOS or melanocarcinoma or melanoma NOS, Melanoma (disorder), Malignant melanoma, no ICD-O subtype (morphologic abnormality), Malignant melanoma, no International Classification of Diseases for Oncology subtype (morphologic abnormality), Malignant melanoma, no International Classification of Diseases for Oncology subtype, MALIGNANT MELANOMA, MELANOMA, MALIGNANT, malignant melanoma, malignant melanoma (diagnosis), malignant neoplasm melanoma, Melanosarcoma, Malignant melanoma, MM - Malignant melanoma, Malignant melanoma (disorder), Malignant melanoma, NOS, Melanoma, NOS, Malignant melanoma (morphologic abnormality), Malignant melanoma, morphology (morphologic abnormality), melanoma
Portuguese MELANOMA MALIGNO, Melanoma maligno, Melanoma Maligno, Melanoma
Spanish MELANOMA MALIGNO, melanoma maligno, no clasificado como subtipo en CIE-O (anomalía morfológica), melanoma maligno, sin subtipo en la CIE O (anomalía morfológica), melanoma maligno, no clasificado como subtipo en CIE-O, melanoma maligno, sin subtipo en la CIE O, melanoma maligno, morfología, [M]melanoma maligno, SAI (anomalía morfológica), [M]melanoma maligno, SAI, melanoma maligno (anomalía morfológica), melanoma maligno (trastorno), melanoma maligno, melanoma, Melanoma maligno, Melanoma, Melanoma Maligno
Dutch melanoom maligne, melanoom, maligne melanoom, Maligne melanoom, Melanoom
German Melanom boesartig, MELANOM MALIGNE, boesartiges Melanom, Melanom, Bösartiges Melanom
Swedish Melanom
Japanese アクセイコクショクシュ, コクショクシュ, 黒色腫, 悪性黒色腫, メラノーマ, メラノーム, 黒色癌腫, 黒色肉腫, 黒色癌
Czech melanom, Melanom, Maligní melanom, maligní melanom
Finnish Melanooma
Italian Melanoma maligno, Melanoma
Russian MELANOSARKOMA, MELANOMA ZLOKACHESTVENNAIA, MELANOMA, MELANOBLASTOMA, МЕЛАНОБЛАСТОМА, МЕЛАНОМА, МЕЛАНОМА ЗЛОКАЧЕСТВЕННАЯ, МЕЛАНОСАРКОМА
French MELANOME MALIN, Mélanome, Mélanome malin
Croatian MELANOM
Polish Czerniak, Czerniak złośliwy
Hungarian Rosszindulatú melanoma, Melanoma, Melanoma malignum
Norwegian Malignt melanom
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Cutaneous Melanoma (C0151779)

Definition (NCI) A primary melanoma arising from atypical melanocytes in the skin. Precursor lesions include acquired and congenital melanocytic nevi, and dysplastic nevi. Several histologic variants have been recognized, including superficial spreading melanoma, acral lentiginous melanoma, nodular melanoma, and lentigo maligna melanoma.
Concepts Neoplastic Process (T191)
MSH C562393
ICD9 172.9, 172
ICD10 C43, C43.9
SnomedCT 190105009, 269577007, 154501005, 154506000, 188082007, 321031000009106, 93655004
LNC LP36756-2, MTHU019305
English MM-Malignant melanoma of skin, Mal melanoma/skin,unspecfd, Malignant melanoma of skin NOS, Malignant melanoma of skin, unspecified, [X]Mal melanoma/skin,unspecfd, [X]Malignant melanoma of skin, unspecified, Cutaneous Melanoma, FAMMM, DYSPLASTIC NEVUS SYNDROME, HEREDITARY, CMM, MELANOMA, FAMILIAL, FAMILIAL ATYPICAL MOLE-MALIGNANT MELANOMA SYNDROME, DNS, MLM, malignant melanoma of skin (diagnosis), malignant melanoma of skin, Melanoma of skin (malignant), Malignant melanoma of skin stage unspecified, Melanoma skin, Skin melanoma, Malig melanoma skin NOS, Melanomas of skin, Melanoma (malignant) NOS, melanomas of skin, skin cancer melanoma, cutaneous malignant melanoma, melanoma skin cancer, skin melanomas, skin melanoma cancer, malignant melanoma skin, malignant cutaneous melanoma, melanoma skin, skin malignant melanoma, cancer melanoma skin, skin melanoma, MELANOMA, CUTANEOUS MALIGNANT, Cutaneous melanoma, Melanoma, Cutaneous Malignant, Dysplastic Nevus Syndrome, Hereditary, Melanoma, Familial, Fammm, Familial Atypical Mole-Malignant Melanoma Syndrome, [X]Malignant melanoma of skin, unspecified (disorder), Malignant melanoma of skin NOS (disorder), Melanoma of skin (disorder), Melanoma of skin, Malignant melanoma of skin, Cutaneous malignant melanoma, MM - Malignant melanoma of skin, Malignant melanoma of skin (disorder), cutaneous melanoma, melanoma, cutaneous, Skin cancer, melanoma, melanoma; skin, skin; melanoma, Malignant melanoma of skin, NOS, Malignant Cutaneous Melanoma, Malignant Melanoma (of Skin), Stage Unspecified, Malignant Melanoma of Skin Stage Unspecified, Malignant Melanoma of Skin, Melanoma of Skin, Melanoma of the Skin, Skin Melanoma, Skin, Melanoma, Melanoma of skin, site unspecified
Dutch melanoom van de huid, plaats niet-gespecificeerd, melanoom van de huid (maligne), maligne melanoom van de huid, melanoom huid, melanoom van de huid maligne niet-gespecificeerd stadium, huidmelanoom, huid; melanoom, melanoom; huid, Maligne melanoom van huid, niet gespecificeerd, Maligne melanoom van huid
French Mélanome cutané (malin), Mélanome malin cutané stade non précisé, Mélanome cutané, Mélanome cutané malin, Mélanome cutané, site non précisé
German Melanom der Haut (boesartig), Melanom der Haut, Stelle unspezifisch, Hautmelanom, Melanom Haut, boesartiges Melanom der Haut, boesartiges Melanom der Haut Stadium unspezifisch, Boesartiges Melanom der Haut, nicht naeher bezeichnet, Boesartiges Melanom der Haut
Italian Melanoma cutaneo (maligno), Melanoma maligno della cute stadio non specificato, Melanoma cutaneo, sede non specificata, Melanoma della cute, Melanoma maligno della cute, Melanoma cutaneo
Portuguese Melanoma cutâneo maligno, Melanoma cutâneo, Melanoma cutâneo de localização NE, Melanoma maligno da pele, Melanoma maligno cutâneo estádio NE
Spanish Melanoma maligno de piel en estadio no especificado, Melanoma de piel, zona no especificada, Melanoma maligno de la piel, Melanoma de piel (maligno), Melanoma de piel, Melanoma cutáneo, melanoma maligno cutáneo, SAI, melanoma maligno de piel, SAI (trastorno), [X]melanoma maligno de piel, no especificado (trastorno), Malignant melanoma of skin NOS, melanoma maligno de piel, SAI, [X]melanoma maligno de piel, no especificado, melanoma maligno de la piel (trastorno), melanoma maligno de la piel
Japanese 皮膚悪性黒色腫、病期不明, 皮膚の悪性黒色腫, ヒフアクセイコクショクシュビョウキフメイ, ヒフノアクセイコクショクシュ, ヒフコクショクシュアクセイ, ヒフコクショクシュ, 皮膚黒色腫(悪性), 皮膚黒色腫
Czech Melanom kůže blíže neurčené lokalizace, Maligní melanom kůže, Melanom kůže (maligní), Melanom kůže, Maligní melanom kůže blíže neurčeného stadia, Kožní melanom
Korean 상세불명의 피부의 악성 흑색종, 피부의 악성 흑색종
Hungarian Bőrmelanoma (malignus), Bőrmelanoma, Bőr malignus melanomája, Bőr nem meghatározott stádiumú malignus melanomája, Bőr nem meghatározott helyű melanomája, Bőr melanomája
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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