Malignant Melanoma Clinical Presentation

  • Author: Winston W Tan, MD; Chief Editor: Jules E Harris, MD   more...
 
Updated: Apr 12, 2012
 

History

Family history

Carefully obtain any family history of melanoma or skin cancer. Also, a family history of irregular, prominent moles is important. Approximately 10% of all patients with melanoma have a family history of melanoma. These patients typically develop melanoma at an earlier age and tend to have multiple dysplastic nevi. These patients also are more likely to have multiple primaries. Presence of a familial melanoma syndrome should be considered in patients with a family history of pancreatic cancer or astrocytoma. Mutations in the CDKN2A tumor suppressor gene (also known as p16) are the most common genetic abnormalities found in these families.

Patient history

Any previous history of melanoma must be elicited from patients, because these patients are at increased risk of developing a second melanoma. Patients have reported as many as 8 or more primary melanomas. Multiple primaries especially are prevalent in patients with multiple dysplastic nevi. The term familial atypical mole or melanoma (FAMM) syndrome is used to describe this hereditary tendency to develop multiple dysplastic nevi and melanomas.

Sun exposure

Question the patient extensively about previous sun exposure, including severe sunburns in childhood. The capacity to tan is also important, because individuals who tan easily are less likely to develop a melanoma than those who burn easily.

Moles

Question the patient about any changes noted in moles. Any history of change in size, color, or symmetry, as well as knowledge of bleeding or ulceration of the lesion must be obtained. Also elicit any history or family history of multiple nevus syndrome.

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Physical Examination

Total body examination

A total-body skin examination is crucial when evaluating a patient with an atypical nevus or a melanoma. The skin examination should be performed on initial evaluation of the patient and during all subsequent visits. A study from a general dermatology practice found that most melanomas diagnosed during a 3-year period were not the presenting complaint but were discovered only because a dermatologist performed a total-body skin examination; moreover, these incidentally discovered melanomas were more likely to be thinner or in-situ lesions.[9]

Crucial to a good skin examination is a well-lit examining room and a completely disrobed patient.

Serial photography and new techniques, such as epiluminescence microscopy and computerized image analysis, are useful adjuncts. Epiluminescence microscopy uses a magnifying lens to examine a lesion that has had oil applied. Computerized image analysis stores images of the lesions and makes them available for comparison over time.

Skin examination

During a skin examination, assess the total number of nevi present on the patient's skin. Attempt to differentiate between typical and atypical lesions. (The images below depict examples of melanomas.) The ABCDs for differentiating early melanomas from benign nevi include the following:

  • A - Asymmetry (melanoma lesion more likely to be asymmetrical)
  • B - Border irregularity (melanoma more likely to have irregular borders)
  • C - Color (melanoma more likely to be very dark black or blue and to have variation in color than would a benign mole, which more often is uniform in color and light tan or brown)
  • D - Diameter (mole < 6 mm in diameter usually benign)A 1.5-cm melanoma with characteristic asymmetry, iA 1.5-cm melanoma with characteristic asymmetry, irregular borders, and color variation. Malignant melanoma. Image courtesy of Hon Pak, MD.Malignant melanoma. Image courtesy of Hon Pak, MD. Lentigo maligna melanoma, right lower cheek. The cLentigo maligna melanoma, right lower cheek. The centrally located erythematous papule represents invasive melanoma with surrounding macular lentigo maligna (melanoma in situ). Image courtesy of Susan M. Swetter, MD.

Lymph node examination

If a patient is diagnosed with a melanoma, examine all lymph node groups. Melanoma may disseminate through the lymphatics, leading to the involvement of regional lymph nodes, and hematogenously, leading to the involvement of any node basin in the body.

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Contributor Information and Disclosures
Author

Winston W Tan, MD  Assistant Professor of Medicine, Mayo Medical School; Consulting Staff, Mayo Group Practices

Winston W Tan, MD is a member of the following medical societies: American College of Physicians, American Society of Clinical Oncology, American Society of Hematology, Philippine Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Philip Schulman, MD  Chief, Medical Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center

Philip Schulman, MD, is a member of the following medical societies: American Association for Cancer Research, American College of Physicians, American Society of Hematology, and Medical Society of the State of New York

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Chief Editor

Jules E Harris, MD  Clinical Professor of Medicine, Section of Hematology/Oncology, University of Arizona College of Medicine, Arizona Cancer Center

Jules E Harris, MD is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Association of Immunologists, American Society of Hematology, and Central Society for Clinical Research

Disclosure: GlobeImmune Salary Consulting

References

  1. Balch CM, Buzaid AC, Soong SJ, Atkins MB, Cascinelli N, Coit DG, et al. Final version of the American Joint Committee on Cancer staging system for cutaneous melanoma. J Clin Oncol. Aug 15 2001;19(16):3635-48. [Medline].

  2. American Joint Committee on Cancer. AJCC Staging Manual. 6th edition. 2002.

  3. American Cancer Society. Cancer Facts & Figures 2009. Available at http://www.cancer.org/downloads/STT/500809web.pdf. Accessed August 25, 2009.

  4. Shaikh WR, Xiong M, Weinstock MA. The contribution of nodular subtype to melanoma mortality in the United States, 1978 to 2007. Arch Dermatol. Jan 2012;148(1):30-6. [Medline].

  5. Murali R, Desilva C, Thompson JF, Scolyer RA. Factors predicting recurrence and survival in sentinel lymph node-positive melanoma patients. Ann Surg. Jun 2011;253(6):1155-64. [Medline].

  6. Mocellin S, Pasquali S, Riccardo Rossi C, Nitti D. Validation of the prognostic value of lymph node ratio in patients with cutaneous melanoma: A population-based study of 8,177 cases. Surgery. Jul 2011;150(1):83-90. [Medline].

  7. Brewer JD, Christenson LJ, Weaver AL, et al. Malignant melanoma in solid transplant recipients: collection of database cases and comparison with surveillance, epidemiology, and end results data for outcome analysis. Arch Dermatol. Jul 2011;147(7):790-6. [Medline].

  8. Jethanamest D, Vila PM, Sikora AG, Morris LG. Predictors of survival in mucosal melanoma of the head and neck. Ann Surg Oncol. Oct 2011;18(10):2748-56. [Medline]. [Full Text].

  9. Kantor J, Kantor DE. Routine dermatologist-performed full-body skin examination and early melanoma detection. Arch Dermatol. Aug 2009;145(8):873-6. [Medline].

  10. Sabel MS, Wong SL. Review of evidence-based support for pretreatment imaging in melanoma. J Natl Compr Canc Netw. Mar 2009;7(3):281-9. [Medline].

  11. Xing Y, Bronstein Y, Ross MI, Askew RL, Lee JE, Gershenwald JE, et al. Contemporary diagnostic imaging modalities for the staging and surveillance of melanoma patients: a meta-analysis. J Natl Cancer Inst. Jan 19 2011;103(2):129-42. [Medline]. [Full Text].

  12. Bronstein Y, Ng CS, Rohren E, Ross MI, Lee JE, Cormier J, et al. PET/CT in the Management of Patients With Stage IIIC and IV Metastatic Melanoma Considered Candidates for Surgery: Evaluation of the Additive Value After Conventional Imaging. AJR Am J Roentgenol. Apr 2012;198(4):902-8. [Medline].

  13. Grotz TE, Markovic SN, Erickson LA, et al. Mayo Clinic consensus recommendations for the depth of excision in primary cutaneous melanoma. Mayo Clin Proc. Jun 2011;86(6):522-8. [Medline]. [Full Text].

  14. Gillgren P, Drzewiecki KT, Niin M, et al. 2-cm versus 4-cm surgical excision margins for primary cutaneous melanoma thicker than 2 mm: a randomised, multicentre trial. Lancet. Nov 5 2011;378(9803):1635-42. [Medline].

  15. Bachter D, Michl C, Büchels H, Vogt H, Balda BR. The predictive value of the sentinel lymph node in malignant melanomas. Recent Results Cancer Res. 2001;158:129-36. [Medline].

  16. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Melanoma v.2. Available at http://www.nccn.org/professionals/physician_gls/PDF/melanoma.pdf. Accessed August 25, 2009.

  17. Andtbacka RH, Gershenwald JE. Role of sentinel lymph node biopsy in patients with thin melanoma. J Natl Compr Canc Netw. Mar 2009;7(3):308-17. [Medline].

  18. [Best Evidence] Cadili A, McKinnon G, Wright F, Hanna W, Macintosh E, Abhari Z, et al. Validation of a scoring system to predict non-sentinel lymph node metastasis in melanoma. J Surg Oncol. Mar 1 2010;101(3):191-4. [Medline].

  19. McWilliams RR, Rao RD, Buckner JC, Link MJ, Markovic S, Brown PD. Melanoma-induced brain metastases. Expert Rev Anticancer Ther. May 2008;8(5):743-55. [Medline].

  20. [Best Evidence] Gould Rothberg BE, Berger AJ, Molinaro AM, Subtil A, Krauthammer MO, Camp RL, et al. Melanoma prognostic model using tissue microarrays and genetic algorithms. J Clin Oncol. Dec 1 2009;27(34):5772-80. [Medline]. [Full Text].

  21. Kirkwood JM, Strawderman MH, Ernstoff MS, Smith TJ, Borden EC, Blum RH. Interferon alfa-2b adjuvant therapy of high-risk resected cutaneous melanoma: the Eastern Cooperative Oncology Group Trial EST 1684. J Clin Oncol. Jan 1996;14(1):7-17. [Medline].

  22. [Best Evidence] Kirkwood JM, Manola J, Ibrahim J, Sondak V, Ernstoff MS, Rao U. Eastern Cooperative Oncology Group. A pooled analysis of Eastern Cooperative Oncology Group and intergroup trials of adjuvant high dose alpha interferon for melanoma. Clin Cancer Res. 2004;10:1670-77.

  23. [Best Evidence] Pectasides D, Dafni U, Bafaloukos D, Skarlos D, Polyzos A, Tsoutsos D, et al. Randomized phase III study of 1 month versus 1 year of adjuvant high-dose interferon alfa-2b in patients with resected high-risk melanoma. J Clin Oncol. Feb 20 2009;27(6):939-44. [Medline].

  24. [Best Evidence] Hauschild A, Weichenthal M, Rass K, Linse R, Ulrich J, Stadler R, et al. Prospective randomized multicenter adjuvant dermatologic cooperative oncology group trial of low-dose interferon alfa-2b with or without a modified high-dose interferon alfa-2b induction phase in patients with lymph node-negative melanoma. J Clin Oncol. Jul 20 2009;27(21):3496-502. [Medline].

  25. [Best Evidence] Hauschild A, Weichenthal M, Rass K, Linse R, Berking C, Böttjer J, et al. Efficacy of low-dose interferon {alpha}2a 18 versus 60 months of treatment in patients with primary melanoma of >= 1.5 mm tumor thickness: results of a randomized phase III DeCOG trial. J Clin Oncol. Feb 10 2010;28(5):841-6. [Medline].

  26. Eggermont AM, Suciu S, Testori A, et al. Ulceration and stage are predictive of interferon efficacy in melanoma: results of the phase III adjuvant trials EORTC 18952 and EORTC 18991. Eur J Cancer. Jan 2012;48(2):218-25. [Medline].

  27. Spitler LE, Grossbard ML, Ernstoff MS, Silver G, Jacobs M, Hayes FA, et al. Adjuvant therapy of stage III and IV malignant melanoma using granulocyte-macrophage colony-stimulating factor. J Clin Oncol. Apr 2000;18(8):1614-21. [Medline].

  28. Flaherty KT, Puzanov I, Kim KB, Ribas A, McArthur GA, Sosman JA, et al. Inhibition of mutated, activated BRAF in metastatic melanoma. N Engl J Med. Aug 26 2010;363(9):809-19. [Medline].

  29. Chapman PB, Hauschild A, Robert C, et al. Improved survival with vemurafenib in melanoma with BRAF V600E mutation. N Engl J Med. Jun 30 2011;364(26):2507-16. [Medline].

  30. Fecher LA, Flaherty KT. Where are we with adjuvant therapy of stage III and IV melanoma in 2009?. J Natl Compr Canc Netw. Mar 2009;7(3):295-304. [Medline].

  31. Lens MB, Reiman T, Husain AF. Use of tamoxifen in the treatment of malignant melanoma. Cancer. Oct 1 2003;98(7):1355-61. [Medline].

  32. Carvajal RD, Antonescu CR, Wolchok JD, et al. KIT as a therapeutic target in metastatic melanoma. JAMA. Jun 8 2011;305(22):2327-34. [Medline].

  33. Middleton MR, Grob JJ, Aaronson N, Fierlbeck G, Tilgen W, Seiter S, et al. Randomized phase III study of temozolomide versus dacarbazine in the treatment of patients with advanced metastatic malignant melanoma. J Clin Oncol. Jan 2000;18(1):158-66. [Medline].

  34. Atkins MB, Lotze MT, Dutcher JP, Fisher RI, Weiss G, Margolin K, et al. High-dose recombinant interleukin 2 therapy for patients with metastatic melanoma: analysis of 270 patients treated between 1985 and 1993. J Clin Oncol. Jul 1999;17(7):2105-16. [Medline].

  35. Hauschild A, Agarwala SS, Trefzer U, Hogg D, Robert C, Hersey P, et al. Results of a phase III, randomized, placebo-controlled study of sorafenib in combination with carboplatin and paclitaxel as second-line treatment in patients with unresectable stage III or stage IV melanoma. J Clin Oncol. Jun 10 2009;27(17):2823-30. [Medline].

  36. Perez DG, Suman VJ, Fitch TR, Amatruda T III, Morton RF, Jilani SZ, et al. Phase II trial of carboplatin, weekly paclitaxel, and weekly bevacizumab in patients with unresectable stage IV melanoma: a North Central Cancer Treatment Group study, N047A. Cancer. Jan 2009;115(1):119-27.

  37. [Best Evidence] Maio M, Mackiewicz A, Testori A, Trefzer U, Ferraresi V, Jassem J, et al. Large randomized study of thymosin alpha 1, interferon alfa, or both in combination with dacarbazine in patients with metastatic melanoma. J Clin Oncol. Apr 1 2010;28(10):1780-7. [Medline].

  38. Kirkwood JM, Ibrahim JG, Sosman JA, Sondak VK, Agarwala SS, Ernstoff MS, et al. High-dose interferon alfa-2b significantly prolongs relapse-free and overall survival compared with the GM2-KLH/QS-21 vaccine in patients with resected stage IIB-III melanoma: results of intergroup trial E1694/S9512/C509801. J Clin Oncol. May 1 2001;19(9):2370-80. [Medline].

  39. Sasse AD, Sasse EC, Clark LG, Ulloa L, Clark OA. Chemoimmunotherapy versus chemotherapy for metastatic malignant melanoma. Cochrane Database Syst Rev. Jan 24 2007;CD005413. [Medline].

  40. Sarnaik AA, Weber JS. Recent advances using anti-CTLA-4 for the treatment of melanoma. Cancer J. May-Jun 2009;15(3):169-73. [Medline].

  41. Hodi FS, O'Day SJ, et al. Improved survival with ipilimumab in patients with metastatic melanoma. N Engl J Med. Aug 19 2010;363(8):711-23. [Medline].

  42. Robert C, Thomas L, Bondarenko I, et al. Ipilimumab plus dacarbazine for previously untreated metastatic melanoma. N Engl J Med. Jun 30 2011;364(26):2517-26. [Medline].

  43. Eggermont AM, Suciu S, Santinami M, Testori A, Kruit WH, Marsden J, et al. Adjuvant therapy with pegylated interferon alfa-2b versus observation alone in resected stage III melanoma: final results of EORTC 18991, a randomised phase III trial. Lancet. Jul 12 2008;372(9633):117-26. [Medline].

  44. Huncharek M, Kupelnick B. Use of topical sunscreen and the risk of malignant melanoma. Results of a meta-analysis of 9,067 patients. Ann Epidemiol. Oct 1 2000;10(7):467. [Medline].

  45. Autier P, Boniol M, Doré JF. Sunscreen use and increased duration of intentional sun exposure: still a burning issue. Int J Cancer. Jul 1 2007;121(1):1-5. [Medline].

  46. Hancock BW, Wheatley K, Harris S, Ives N, Harrison G, Horsman JM, et al. Adjuvant interferon in high-risk melanoma: the AIM HIGH Study--United Kingdom Coordinating Committee on Cancer Research randomized study of adjuvant low-dose extended-duration interferon Alfa-2a in high-risk resected malignant melanoma. J Clin Oncol. Jan 1 2004;22(1):53-61. [Medline].

 
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A 1.5-cm melanoma with characteristic asymmetry, irregular borders, and color variation.
Malignant melanoma. Image courtesy of Hon Pak, MD.
Lentigo maligna melanoma, right lower cheek. The centrally located erythematous papule represents invasive melanoma with surrounding macular lentigo maligna (melanoma in situ). Image courtesy of Susan M. Swetter, MD.
 
 
 
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