Diagnostic Considerations

For subungual melanoma, also consider chronic paronychia, subungual hematoma, and melanonychia striata. For superficial spreading or nodular subtypes, also consider traumatized nevus.

Differential Diagnoses

Workup

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Media Gallery

Superficial spreading melanoma, left breast, 1.3-mm Breslow depth.
Lentigo maligna melanoma, right lower cheek. Centrally located erythematous papule represents invasive melanoma with surrounding macular lentigo maligna (melanoma in situ).
Acral lentiginous melanoma (1-mm Breslow depth), left sole. Diagnostic punch biopsy site is located superiorly.
Malignant melanoma. Courtesy of Hon Pak, MD.
Cutaneous melanoma with characteristic asymmetry, irregular borders, and color variation. Courtesy of Wendy Brick, MD.

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Table. AJCC Eighth Edition Melanoma Staging (2018)

Table. AJCC Eighth Edition Melanoma Staging (2018)

Clinical Stage	TNM Classification	Histologic/Clinical Features	5-Year Survival Rate, %
0	Tis N0 M0	Intraepithelial/in situ melanoma	100
IA	T1a N0 M0	< 0.8 mm without ulceration	99
IB	T1b N0 M0 T2a N0 M0	< 0.8 mm with ulceration or 0.8 mm with or without ulceration >1.0-2.0 mm without ulceration	99 96
IIA	T2b N0 M0 T3a N0 M0	>1.0-2.0 mm with ulceration >2.0-4.0 mm without ulceration	93 94
IIB	T3b N0 M0 T4a N0 M0	>2.0-4.0 mm with ulceration >4.0 mm without ulceration	86 90
IIC	T4b N0 M0	>4.0 mm with ulceration	82
IIIA	T1a/b, T2a N1a M0 T1a/b, T2a N2a M0	1 regional nodal micrometastasis (clinically occult), without lymphatic metastasis, ulcerated primary ≤1.0 mm or nonulcerated primary ≤2.0 mm 2-3 microscopic positive regional nodes (clinically occult) without lymphatic metastasis, ulcerated primary ≤1.0 mm or nonulcerated primary ≤2.0 mm	93
IIIB	T1a/b, T2a N1b/c, N2a/b M0 T2b, T3a N1a/b/c, N2a/b M0	1 regional nodal macrometastasis (clinically detected) without lymphatic metastasis, or no lymph node disease with lymphatic metastasis, ulcerated primary ≤1.0 mm or nonulcerated primary ≤2.0 mm 2-3 regional nodal macrometastasis (clinically detected) or 2-3 involved nodes, at least one of which was clinically detected without lymphatic metastasis, ulcerated primary ≤1.0 mm or nonulcerated primary ≤2.0 mm 1 regional nodal micrometastasis (clinically occult), or 1 regional nodal nodal macrometastasis (clinically detected) without lymphatic metastasis, or no regional lymph node disease with lymphatic metastasis*, ulcerated primary >1.0-2.0 mm or nonulcerated primary >2.0-4.0 mm	83
IIIC	T1a/b, T2a/b, T3a N2c, N3a/b/c M0 T3b, T4a, Any N ≥ N1 M0 T4b N1a/b/c, N2a/b/c	1 clinically occult or clinically detected metastasis with lymphatic metastasis, or 4+ regional nodal micrometatasis (clinically occult) or 4+ tumor involved nodes, at least 1 of which was clinically detected, or any matted nodes without lymphatic metastasis, or 2+ clinically occult or clinically detected and/or matted nodes with lymphatic metastasis, ulcerated or nonulcerated primary ≤2.0 mm or nonulcerated primary >2.0-4.0 mm N2 or N3 disease with ulcerated primary >2.0-4.0 mm or nonulcerated primary >4.0 mm One regional nodal micrometastasis (clinically occult), or one regional nodal macrometastasis (clinically detected) without lymphatic metastasis or no regional lymph node disease with lymphatic metastasis, ulcerated primary >4.0 mm 2-3 regional nodal macrometastasis (clinically detected) or 2-3 involved nodes, at least one of which was clinically detected without lymphatic metastasis, or one clinically occult or clinically detected involved node with lymphatic metastasis*, ulcerated primary >4.0 mm	69
IIID	T4b N3a/b/c M0	4+ regional nodal micrometastasis (clinically occult) or 4+ tumor involved nodes, at least 1 of which was clinically detected, or any matted nodes without lymphatic metastasis, or 2+ clinically occult or clinically detected and/or matted nodes with lymphatic metastasis, ulcerated primary >4.0 mm	32
IV	Any T, Tis Any N M1a Any T, Tis Any N M1b Any T, Tis Any N M1c Any T, Tis Any N M1d	Distant skin, soft tissue/muscle and/or nonregional lymph node metastasis with normal [M1a(0)] or elevated [M1a(1)] LDH levels Distant metastasis to non-CNS* visceral sites with or without M1a or M1b sites of disease lung with normal [M1b(0)] or elevated [M1b(1)] LDH levels All other visceral metastasis with normal LDH or any distant metastasis with elevated LDH with normal [M1c(0)] or elevated [M1c(1)] LDH levels Distant metastasis to CNS with or without M1a, M1b, or M1c sites of disease with normal [M1d(0)] or elevated [M1d(1)] LDH levels
Lymphatic metastasis is presence of in-transit, satellite, and/or microsatellite metastasis. LDH is lactate dehydrogenase. **CNS is central nervous system.

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Author

Susan M Swetter, MD Director, Pigmented Lesion and Melanoma Program, Professor, Department of Dermatology, Stanford University Medical Center and Cancer Institute, Veterans Affairs Palo Alto Health Care System

Susan M Swetter, MD is a member of the following medical societies: American Academy of Dermatology, Women's Dermatologic Society, American Society of Clinical Oncology, Society for Melanoma Research, Eastern Cooperative Oncology Group, American Medical Association, Pacific Dermatologic Association, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Dermatologic/Mohs Surgeon, The Surgery Center at Plano Dermatology

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

John G Albertini, MD Private Practice, The Skin Surgery Center; Clinical Associate Professor (Volunteer), Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine; Past President, American College of Mohs Surgery

John G Albertini, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: QualDerm Partners; Novascan<br/>Have a 5% or greater equity interest in: QualDerm Partners - North Carolina.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Acknowledgements

Günter Burg, MD Professor and Chairman Emeritus, Department of Dermatology, University of Zürich School of Medicine; Delegate of The Foundation for Modern Teaching and Learning in Medicine Faculty of Medicine, University of Zürich, Switzerland

Günter Burg, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, International Society for Dermatologic Surgery, North American Clinical Dermatologic Society, and Pacific Dermatologic Association

Disclosure: Nothing to disclose.