Cutaneous Malignant Melanoma: A Primary Care Perspective

Am Fam Physician. 2012 Jan 15;85(2):161-168.

  Patient information: See related handout on cutaneous malignant melanoma, written by the author of this article.

Cutaneous malignant melanoma accounts for 3 to 5 percent of all skin cancers and is responsible for approximately 75 percent of all deaths from skin cancer. Persons with an increased number of moles, dysplastic (also called atypical) nevi, or a family history of the disease are at increased risk compared with the general population. An important tool to assist in the evaluation of potential melanomas for patients and health care professionals is the ABCDE mnemonic, which takes into account asymmetry, border irregularities, color variation, diameter, and evolution. Any suspicious pigmented lesion should be biopsied. Appropriate methods of biopsy can vary, and include deep shave, punch, and excisional biopsy. Regardless of the procedure selected, it is essential that the size of the specimen be adequate to determine the histologic depth of lesion penetration, which is known as the Breslow depth. The Breslow depth is the most important prognostic parameter in evaluating the primary tumor. Because early detection and treatment can lead to identification of thinner lesions, which may increase survival, it is critical that physicians be comfortable with evaluating suspicious pigmented lesions and providing treatment or referral as necessary.

Cutaneous malignant melanoma (CMM) is a potentially lethal form of skin cancer. Although it comprises only 3 to 5 percent of all skin cancers, it is responsible for approximately 75 percent of all deaths from skin cancers.1,2 CMM results from the malignant transformation of melanocytes, which are the pigment-producing cells responsible for the color of skin. The key triggers leading to malignant transformation of melanocytes have yet to be fully elucidated, but are multifactorial and include UV radiation damage and genetic susceptibility.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References Comments

Some organizations recommend including a skin examination during periodic health examinations for adults; however, the U.S. Preventive Services Task Force found insufficient evidence to recommend for or against annual screening for skin cancer.

C

2, 8, 9

There is no statistically significant difference in survival for narrow vs. wide surgical margins for treatment of cutaneous malignant melanoma.

B

1

Statistically insignificant benefit for wide margins

Sentinel node biopsy in persons with melanoma with a Breslow depth of 1.0 mm or greater is useful for determining staging and prognosis.

C

20, 30, 32

Sentinel node biopsy is effective for determining staging and prognosis; no increase in survival has been proven


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References Comments

Some organizations recommend including a skin examination during periodic health examinations for adults; however, the U.S. Preventive Services Task Force found insufficient evidence to recommend for or against annual screening for skin cancer.

C

2, 8, 9

There is no statistically significant difference in survival for narrow vs. wide surgical margins for treatment of cutaneous malignant melanoma.

B

1

Statistically insignificant benefit for wide margins

Sentinel node biopsy in persons with melanoma with a Breslow depth of 1.0 mm or greater is useful for determining staging and prognosis.

C

20, 30, 32

Sentinel node biopsy is effective for determining staging and prognosis; no increase in survival has been proven


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

Incidence and Mortality

The incidence of CMM is highest in white persons. This population is approximately 20 times more likely to develop the disease than black persons. It is rare in young persons, with only 2 percent of melanomas occurring in persons younger than 20 years and approximately 0.3 percent in children younger than 14 years.3 It is the most common cancer in women 25 to 29 years of age, and is second only to breast cancer in women 30 to 34 years of age.4  Based on 2004 to 2008 data, the overall age-adjusted incidence of CMM was 20.8 per 100,000 men and women per year (Table 1).5 However, the annual incidence has increased significantly in white men older than 65 years (8.8 percent per year since 2003), and these men are twice as likely as women in the same age group to develop CMM.4,6 Persons with an increased number of moles, dysplastic (also called atypical) nevi, or a family history of the disease are at increased risk compared with the general population.

Table 1.

Annual Incidence of Cutaneous Malignant Melanoma in the United States from 2004 to 2008

Race/ethnicity Male (per 100,000) Female (per 100,000)

All

26.7

16.7

White

30.9

19.7

Black

1.2

0.9

Asian/Pacific Islander

1.6

1.3

American Indian/Alaska Native

3.9

3.7

Hispanic

4.0

3.9


Adapted from the National Cancer Institute. SEER stat fact sheets: melanoma of the skin. http://seer.cancer.gov/statfacts/html/melan.html. Accessed July 6, 2011.

Table 1.   Annual Incidence of Cutaneous Malignant Melanoma in the United States from 2004 to 2008

View Table

Table 1.

Annual Incidence of Cutaneous Malignant Melanoma in the United States from 2004 to 2008

Race/ethnicity Male (per 100,000) Female (per 100,000)

All

26.7

16.7

White

30.9

19.7

Black

1.2

0.9

Asian/Pacific Islander

1.6

1.3

American Indian/Alaska Native

3.9

3.7

Hispanic

4.0

3.9


Adapted from the National Cancer Institute. SEER stat fact sheets: melanoma of the skin. http://seer.cancer.gov/statfacts/html/melan.html. Accessed July 6, 2011.

Diagnosis

CMM can occur de novo or in a preexisting nevus; therefore, close examination of all nevi on a patient is necessary.7 This may be a daunting task in a busy primary care environment, particularly given the other myriad problems that require evaluation at any particular visit. Some organizations recommend including a skin examination during periodic health examinations for adults; however, the U.S. Preventive Services Task Force concluded that there is not enough evidence to recommend for or against annual whole-body skin examination by a primary care physician or patient for early detection of skin cancers in the adult general population.2,8,9 This recommendation was directed toward patients without a history of premalignant or malignant lesions. Although it makes intuitive sense to counsel patients on disease prevention and to screen them periodically, there is not yet strong evidence to support these practices. The Web site FamilyDoctor.org presents a guideline for patients on skin cancer prevention and self-screening at http://familydoctor.org/familydoctor/en/diseases-conditions/skin-cancer.html.

ABCDE MNEMONIC

The ABCD mnemonic for pigmented skin lesions was first devised in 1985, but continues to be an important tool for patients and health care professionals.1014  It was further modified in 2004 with the addition of “E” to identify evolving lesions. The mnemonic takes into account asymmetry, border irregularities, color variation, diameter, and evolution to assist in the evaluation of potential melanomas (Table 215). Evolution of a lesion has been shown in some studies to be the most specific finding that may indicate melanoma.16,17

Table 2.

ABCDE Mnemonic for Evaluating Melanoma

Asymmetry

One-half of lesion is different than the other half

Border

Irregular or poorly defined border

Color

Varied from one area to another; different shades of tan, brown, black; sometimes red, white, or blue within the same lesion

Diameter

Larger than 6 mm (bigger than the size of a pencil eraser)

Evolving

A mole that looks different compared with surrounding moles (“ugly duckling” sign), or the mole is changing in size, shape, or color


Information from reference 15.

Table 2.   ABCDE Mnemonic for Evaluating Melanoma

View Table

Table 2.

ABCDE Mnemonic for Evaluating Melanoma

Asymmetry

One-half of lesion is different than the other half

Border

Irregular or poorly defined border

Color

Varied from one area to another; different shades of tan, brown, black; sometimes red, white, or blue within the same lesion

Diameter

Larger than 6 mm (bigger than the size of a pencil eraser)

Evolving

A mole that looks different compared with surrounding moles (“ugly duckling” sign), or the mole is changing in size, shape, or color


Information from reference 15.

“UGLY DUCKLING” SIGN

The “ugly duckling” sign is a recent and novel technique to aid in the detection of melanoma. It is a simple and easy-to-teach method based on the concept that a melanoma may look different compared with surrounding moles.18

DERMOSCOPY

Dermoscopy (also termed dermatoscopy in some literature) is used in the evaluation of many types of skin lesions. A device (called a dermascope or dermatoscope) shines polarized light on the skin and magnifies skin lesions with or without a fluid interface (i.e., water, immersion oil, or alcohol), allowing the physician to see pigment and structures in the skin without obstruction by skin surface reflections. Pigment and structures in the skin can give important clues to histology. CMM can have some highly specific dermoscopic features, which can increase the index of suspicion regarding a given lesion and lead the primary care physician to perform a biopsy.

Dermoscopy is a useful tool that has been shown to increase the accuracy of a dermatologist in diagnosing a melanoma by 10 to 27 percent.16 In one study of primary care physicians who used dermoscopy after a one-day training course, the physicians were able to increase their sensitivity for detecting melanoma by approximately 25 percent.16 Training is paramount to the success of dermoscopy. Continuing medical education courses and online tutorials are available. A series of videos produced by Thomas Habif, MD, is useful and includes information on dermoscopy (http://www.youtube.com/watch?v=GkP_Jf6utR4); dermascopes (http://www.youtube.com/watch?v=29Rv2EcBTMs); superficial spreading melanoma (http://www.youtube.com/watch?v=JMIkd6devDo); and color of nevi (http://www.youtube.com/watch?v=V8Z6XDcz53g).

BIOPSY

Any suspicious pigmented lesion should be biopsied. However, the actual method performed has been the source of much study. The generally preferred method is complete elliptical excision of the suspicious lesion with a small margin of normal-appearing skin (approximately 3 mm). It is important to clearly document the dimensions of the lesion in the physician's procedure note, with the dimensions of the lesion plus the surgical margin (e.g., preoperative size: 3 × 4 mm; surgical margins: 3 mm; postoperative size: 9 × 10 mm; postoperative wound length: “X” mm or cm). This will serve as a guide for what additional surgical margins may be necessary if a melanoma is diagnosed.

A scoop shave biopsy (saucerization) and a punch biopsy can be appropriate options depending on the comfort level of the physician and the clinical situation.1921 Given that the Breslow depth of CMM is crucial to staging and prognosis, a superficial shave of a suspicious pigmented lesion should be avoided.20 If a melanoma is bisected during biopsy in such a way that the depth of the lesion cannot be determined, this crucial staging tool will be lost. In the case of smaller pigmented lesions, if excisional biopsy is not practical and the entire lesion can be removed with punch biopsy, then punch biopsy is an appropriate option. However, with a larger lesion (particularly a suspected lentigo maligna melanoma), a single punch may not capture the malignant portion,16 and it may be necessary to perform a larger deep shave biopsy of the portion of the lesion with the most atypical appearing pigmentation network. The most important aspect of any method is to obtain an adequate specimen that will allow for a definitive diagnosis (including the measurement of the Breslow depth) or exclusion of melanoma by an experienced pathologist or dermatopathologist.

Proper staging of a melanoma is based on a combination of histologic and clinical features.20 Breslow depth, ulceration, and mitotic rate (number of mitoses per square millimeter) are three crucial features in the staging and ultimate prognosis of a patient's disease. Although presence of tumor ulceration increases the stage of a specific tumor, the Breslow depth and mitotic rate are the most powerful predictors of survival.20

TYPES

Melanoma in Situ (Figure 1). In this type of CMM, the malignant melanocytes are confined to the epidermis. No invasion has yet occurred. Early diagnosis of melanoma in situ is considered curative by excision with 5-mm margins.22

Figure 1.

Malignant melanoma in situ.

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Figure 1.

Malignant melanoma in situ.


Figure 1.

Malignant melanoma in situ.

Superficial Spreading Melanoma (Figure 2). This is the most common type of CMM in persons with fair skin. It often has an initial slow radial growth phase before becoming invasive. Superficial spreading melanoma often begins as an asymptomatic brown or black spot (macule) that may have asymmetry, irregular borders, or variations in color.7

Figure 2.

Superficial spreading melanoma with a Breslow depth of 0.45 mm.

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Figure 2.

Superficial spreading melanoma with a Breslow depth of 0.45 mm.


Figure 2.

Superficial spreading melanoma with a Breslow depth of 0.45 mm.

Nodular Melanoma (Figure 3). This is the second most common type of CMM in persons with fair skin. It is not believed to have the radial growth phase that occurs with superficial spreading melanoma.22 Nodular melanoma progresses rapidly as a vertically growing tumor over months, and typically presents as a blue to black nodule, although it can sometimes be pink or red in color. These lesions also may have ulceration and bleeding.

Figure 3.

Nodular melanoma with a Breslow depth of 0.6 mm.

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Figure 3.

Nodular melanoma with a Breslow depth of 0.6 mm.


Figure 3.

Nodular melanoma with a Breslow depth of 0.6 mm.

Lentigo Maligna and Lentigo Maligna Melanoma (Figure 423). These lesions most often occur in persons 60 to 80 years of age with heavily sun-damaged skin.22 Lentigo maligna is an in situ form that slowly grows over five to 15 years before becoming invasive (lentigo maligna melanoma). Lentigo maligna and lentigo maligna melanoma can be fairly large lesions. It is estimated that only 3 to 5 percent of lentigo maligna lesions will become invasive, and it is generally thought that the risk of progression is proportional to the size of the lesion.24 Lentigo maligna usually begins as an irregularly shaped tan spot (macule) that slowly grows to form a larger spot (patch). Invasive changes can be evident with the formation of bumps (papules), but invasion can be difficult to predict based on clinical examination. The mortality rate of lentigo maligna and lentigo maligna melanoma is the same as any other CMM, based on depth of the lesion.

Figure 4.

Lentigo maligna melanoma.

Copyright © Eric Ehrsam, MD, Dermatlas. http://www.dermatlas.org.

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Figure 4.

Lentigo maligna melanoma.

Copyright © Eric Ehrsam, MD, Dermatlas. http://www.dermatlas.org.


Figure 4.

Lentigo maligna melanoma.

Copyright © Eric Ehrsam, MD, Dermatlas. http://www.dermatlas.org.

Amelanotic Melanoma (Figure 5). This type of CMM is an uncommon, nonpigmented variant of melanoma (less than 5 per cent) that can mimic a wide range of benign and malignant conditions, including eczema, fungal infections, basal cell carcinoma, and squamous cell carcinoma.22 Amelanotic melanoma, although not necessarily more lethal, is more often diagnosed in a more advanced and invasive stage than the pigmented types of melanoma.22

Figure 5.

Acral-lentiginous amelanotic melanoma.

Copyright © David Elpern, MD.

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Figure 5.

Acral-lentiginous amelanotic melanoma.

Copyright © David Elpern, MD.


Figure 5.

Acral-lentiginous amelanotic melanoma.

Copyright © David Elpern, MD.

Acral-Lentiginous Melanoma (Figure 6). Acral surfaces are those found on body protrusions, such as the fingertips, knuckles, elbows, knees, buttocks, toes, heels, and ears. Specialized acral skin is found on the palms and soles and lacks hair follicles. Acral-lentiginous melanoma is the least common type of melanoma in white persons, comprising 2 to 8 percent of melanomas. However, it represents approximately 75 percent of the melanomas diagnosed in black and Asian persons.25,26 Acral-lentiginous melanoma is a major concern because of inaccurate notions that black or Asian persons cannot get CMM. As a result, it may go unnoticed until the lesion is in a more advanced stage.25,26 All patients being screened for skin cancer should have their feet examined, similar to the way that all patients with diabetes mellitus should have a foot examination.

Figure 6.

Acral-lentiginous melanoma with a Breslow depth of 4.0 mm.

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Figure 6.

Acral-lentiginous melanoma with a Breslow depth of 4.0 mm.


Figure 6.

Acral-lentiginous melanoma with a Breslow depth of 4.0 mm.

Subungual Melanoma (Figure 7 23). Melanoma of the nail arises from melanocytes in the matrix, and represents 0.7 to 3.5 percent of all melanomas.27 Although pigmented longitudinal lines on the nail plate can be normal, they can also signal that a melanoma has developed in the matrix. New-onset pigmented lines on a single nail (longitudinal melanonychia) are a concerning sign and require a biopsy into the nail matrix to properly evaluate for melanoma.28 This procedure is usually performed by a dermatologist. Patients must be counseled that such a biopsy will invariably result in permanent dystrophy of the nail.

Figure 7.

Subungual melanoma.

Copyright © Paolo Amerio, MD, PhD, Dermatlas. http://www.dermatlas.org.

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Figure 7.

Subungual melanoma.

Copyright © Paolo Amerio, MD, PhD, Dermatlas. http://www.dermatlas.org.


Figure 7.

Subungual melanoma.

Copyright © Paolo Amerio, MD, PhD, Dermatlas. http://www.dermatlas.org.

Types of CMM are listed in Table 3.7,22,2429

Table 3.

Types of Cutaneous Malignant Melanoma

Type Description Percentage of melanomas

Melanoma in situ

Confined to epidermis

Approximately 40

Superficial spreading melanoma

Most common type of cutaneous malignant melanoma in persons with fair skin

70

Typically occur in persons 30 to 50 years of age

Typically occur on the trunk of men and legs of women

Nodular melanoma

Second most common type of cutaneous malignant melanoma in persons with fair skin

10 to 15

Typically occur on the trunk, head, or neck

More common in men than in women

Lentigo maligna and lentigo maligna melanoma

Typically occur in persons 60 to 80 years of age with sun-damaged skin

4 to 15

Very slow growing

Can be large lesions

Amelanotic melanoma

Rare, can mimic benign conditions, often diagnosed at a more advanced stage

Less than 5

Acral-lentiginous melanoma

Rare, but is the most common melanoma in black and Asian persons

2 to 8

Subungual melanoma

Rare, presents as a single longitudinal line of pigmentation on a nail

0.7 to 3.5

Pigmentation may also spread onto the overlying and adjacent proximal or lateral nail folds (Hutchinson sign)


Information from references 7, 22, and 24 through 29.

Table 3.   Types of Cutaneous Malignant Melanoma

View Table

Table 3.

Types of Cutaneous Malignant Melanoma

Type Description Percentage of melanomas

Melanoma in situ

Confined to epidermis

Approximately 40

Superficial spreading melanoma

Most common type of cutaneous malignant melanoma in persons with fair skin

70

Typically occur in persons 30 to 50 years of age

Typically occur on the trunk of men and legs of women

Nodular melanoma

Second most common type of cutaneous malignant melanoma in persons with fair skin

10 to 15

Typically occur on the trunk, head, or neck

More common in men than in women

Lentigo maligna and lentigo maligna melanoma

Typically occur in persons 60 to 80 years of age with sun-damaged skin

4 to 15

Very slow growing

Can be large lesions

Amelanotic melanoma

Rare, can mimic benign conditions, often diagnosed at a more advanced stage

Less than 5

Acral-lentiginous melanoma

Rare, but is the most common melanoma in black and Asian persons

2 to 8

Subungual melanoma

Rare, presents as a single longitudinal line of pigmentation on a nail

0.7 to 3.5

Pigmentation may also spread onto the overlying and adjacent proximal or lateral nail folds (Hutchinson sign)


Information from references 7, 22, and 24 through 29.

Surgical Treatment

Surgical removal is the primary treatment for CMM. The Breslow depth of the lesion determines definitive surgical margins (Table 4).30 The purpose of the surgical margin is to ensure complete removal of the primary lesion and any residual melanoma cells that may have spread into the surrounding skin to definitively treat the lesion and reduce the chance of recurrence. A 2009 Cochrane review involving 3,297 patients examined the association between surgical margins and survival. No statistically significant difference in survival was identified between wide (3 to 5 cm) and narrow (1 to 2 cm) surgical margins.1 This has allowed for narrower surgical margin recommendations, with less morbidity associated with the traditionally wide margins used in the past. If the physician who performed the biopsy is not providing the surgical treatment, then appropriate referral is necessary as soon as possible. Although there is no literature to identify the optimal time from diagnosis to treatment, definitive surgical treatment should usually occur no later than three to four weeks after receipt of the biopsy report.

Table 4.

Recommended Surgical Margins for Melanoma Based on Breslow Depth

Breslow depth Margins

In situ

5 mm

≤ 2.0 mm

1 cm

> 2.0 mm

2 cm


Adapted with permission from Sober AJ, Chuang TY, Duvic M, et al.; Guidelines/Outcomes Committee. Guidelines of care for primary cutaneous melanoma. J Am Acad Dermatol. 2001;45(4):583.

Table 4.   Recommended Surgical Margins for Melanoma Based on Breslow Depth

View Table

Table 4.

Recommended Surgical Margins for Melanoma Based on Breslow Depth

Breslow depth Margins

In situ

5 mm

≤ 2.0 mm

1 cm

> 2.0 mm

2 cm


Adapted with permission from Sober AJ, Chuang TY, Duvic M, et al.; Guidelines/Outcomes Committee. Guidelines of care for primary cutaneous melanoma. J Am Acad Dermatol. 2001;45(4):583.

Treatment of lentigo maligna and lentigo maligna melanoma is challenging. Standard excision with 5-mm to 1-cm margins can have recurrence rates ranging from 8 to 50 percent.31 Such standard margins can leave the patient with a significant surgical defect that requires meticulous repair. Mohs surgery (also known as Mohs micrographic surgery) offers high cure rates with considerable sparing of healthy surrounding tissue. The surgery requires immunohistochemical staining of tissue (needed for identification of melanocytes) and coordination with a pathologist/dermatopathologist; however, immunohistochemical staining and access to a pathologist/dermatopathologist are not typically available in most practices that perform Mohs surgery. Although the procedure offers the possibility of better margin control, it is not yet the accepted standard of care.

In cases in which the Breslow depth is 1.0 mm or greater, the patient is often referred for a sentinel node biopsy. The sentinel node is the first node where cancer is likely to spread to from the primary tumor. Sentinel node biopsy samples the node or nodes that are thought to immediately drain the site of the lesion to identify possible nodal spread. Although the final proof regarding the effect of sentinel node biopsy on survival is yet to be universally determined, it is a useful staging tool and has less morbidity than electively removing the regional nodes.20,21,30,32

Staging and Follow-up Care

The stage of disease is determined by the TNM classification system,20  which takes into account the thickness of the tumor, degree of nodal involvement, and the extent of metastatic spread to other areas of the body. Using this staging information, a treatment plan, follow-up care plan, and statistical survival information with five- and 10-year survival estimates can be determined and discussed with the patient (Table 5).3335

Table 5.

Staging, Survival, and Follow-Up of Cutaneous Malignant Melanoma

StageDescription Survival (%) Specific melanoma follow-up*Additional testing
5-year 10-year

0 (in situ)

Disease confined to epidermis (top layer of skin)

99 to 100

99 to 100

Every six months for first year, then every year up to year 5, then yearly for life

None

I

Confined to skin, but thicker (up to 1.0 mm) and has not spread

IA: 97 IB: 92

IA: 95 IB: 86

Every three to four months for first year, then every six months for second year, then yearly up to year 5, then yearly for life

None

Stage IA: skin covering melanoma remains intact

Stage IB: skin covering melanoma may have broken open (ulcerated)

II

Melanoma has grown thicker, ranging from 1.01 to 4.0 mm, but has not spread

IIA: 81 IIB: 70 IIC: 53

IIA: 67 IIB: 57 IIC: 40

Every three to four months for years 1 through 3, then every six months for years 4 and 5, then yearly for life

CBC, chemistry panel, and LDH level

May or may not have ulcerated

III

Melanoma has spread to one or more nearby lymph nodes or nearby skin

IIIA: 78 IIIB: 59 IIIC: 40

IIIA: 68 IIIB: 43 IIIC: 24

Every three to four months for years 1 through 3, then every six months for years 4 and 5, then yearly for life

CBC, chemistry panel, and LDH level

PET and/or CT as determined by treating physician

IV

Melanoma has spread to an internal organ or lymph nodes further from the original melanoma, or is found on the skin far from the original melanoma

15 to 20

10 to 15

Every three to four months for patients at high risk of relapse Follow-up in patients receiving adjuvant or palliative therapy should be based on the specific treatment prescribed

CBC, chemistry panel, and LDH level

PET and/or CT every two to four months for first five years and then yearly thereafter

Additional testing in patients receiving adjuvant or palliative therapy should be based on the specific treatment prescribed


CBC = complete blood count; CT = computed tomography; LDH = lactate dehydrogenase; PET = positron emission tomography.

*—Follow-up for the first five years is specifically for the diagnosis of melanoma. Annual follow-up for life is recommended to be performed by a dermatologist for routine skin cancer screening.

Information from references 33 through 35.

Table 5.   Staging, Survival, and Follow-Up of Cutaneous Malignant Melanoma

View Table

Table 5.

Staging, Survival, and Follow-Up of Cutaneous Malignant Melanoma

StageDescription Survival (%) Specific melanoma follow-up*Additional testing
5-year 10-year

0 (in situ)

Disease confined to epidermis (top layer of skin)

99 to 100

99 to 100

Every six months for first year, then every year up to year 5, then yearly for life

None

I

Confined to skin, but thicker (up to 1.0 mm) and has not spread

IA: 97 IB: 92

IA: 95 IB: 86

Every three to four months for first year, then every six months for second year, then yearly up to year 5, then yearly for life

None

Stage IA: skin covering melanoma remains intact

Stage IB: skin covering melanoma may have broken open (ulcerated)

II

Melanoma has grown thicker, ranging from 1.01 to 4.0 mm, but has not spread

IIA: 81 IIB: 70 IIC: 53

IIA: 67 IIB: 57 IIC: 40

Every three to four months for years 1 through 3, then every six months for years 4 and 5, then yearly for life

CBC, chemistry panel, and LDH level

May or may not have ulcerated

III

Melanoma has spread to one or more nearby lymph nodes or nearby skin

IIIA: 78 IIIB: 59 IIIC: 40

IIIA: 68 IIIB: 43 IIIC: 24

Every three to four months for years 1 through 3, then every six months for years 4 and 5, then yearly for life

CBC, chemistry panel, and LDH level

PET and/or CT as determined by treating physician

IV

Melanoma has spread to an internal organ or lymph nodes further from the original melanoma, or is found on the skin far from the original melanoma

15 to 20

10 to 15

Every three to four months for patients at high risk of relapse Follow-up in patients receiving adjuvant or palliative therapy should be based on the specific treatment prescribed

CBC, chemistry panel, and LDH level

PET and/or CT every two to four months for first five years and then yearly thereafter

Additional testing in patients receiving adjuvant or palliative therapy should be based on the specific treatment prescribed


CBC = complete blood count; CT = computed tomography; LDH = lactate dehydrogenase; PET = positron emission tomography.

*—Follow-up for the first five years is specifically for the diagnosis of melanoma. Annual follow-up for life is recommended to be performed by a dermatologist for routine skin cancer screening.

Information from references 33 through 35.

Data Sources: A PubMed search was completed in Clinical Queries using the key terms cutaneous melanoma, incidence, diagnosis, and treatment. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Also searched were the Cochrane Database of Systematic Reviews; U.S. Preventive Services Task Force; UpToDate; Surveillance, Epidemiology, and End Results (SEER) Program; National Center for Health Statistics; and the National Cancer Data Base. Search date: July 15, 2010.

The Author

DONALD W. SHENENBERGER, CDR, MC, USN, is a staff dermatologist at the Naval Medical Center Portsmouth (Va.); an assistant professor of dermatology at the Uniformed Services University of the Health Sciences, Bethesda, Md.; and is assigned to Navy Medicine East, Portsmouth, as the regional electronic health record champion.

Address correspondence to Donald W. Shenenberger, CDR, MC, USN, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA 23708 (e-mail: donald.shenenberger@med.navy.mil). Reprints are not available from the author.

Author disclosure: No relevant financial affiliations to disclose.

The author thanks Steven Cronquist, CAPT, MC, USN; Scott McClellan, CDR, MC, USN; and Michael Yablonsky, CDR, MC, USN, for their review of the manuscript and helpful comments.

The opinions and assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Navy, Department of Defense, or the U.S. government.

Figure 2 was provided by Jonathan S. Glass, MD, and Figure 6 was provided by Jonathan Bingham, MD.

REFERENCES

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5. National Cancer Institute. SEER stat fact sheets: melanoma of the skin. http://seer.cancer.gov/statfacts/html/melan.html. Accessed July 6, 2011.

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