Melanoma

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Chapter 35 Melanoma

INTRODUCTION

Description: Melanoma is the malignant degeneration of cells from the melanocytic (pigment) system. Although generally a skin lesion, melanomas may arise in any pigmented tissue (such as the eye). The vulva accounts for 5% to 10% of all malignant melanomas in women, despite containing only 1% of the skin surface.

Prevalence: Found in 4.5 of 100,000, 2007: 59,940 cases, 8110 deaths.

Predominant Age: 20 to 40 years (50% of patients).

Genetics: Familial dysplastic nevus syndrome (if history includes a family member with melanoma, lifetime risk is 100%).

ETIOLOGY AND PATHOGENESIS

Causes: Unknown, may be related to ultraviolet (A and B) light exposure.

Risk Factors: Previous dysplastic nevi, multiple pigmented lesions, fair complexion, freckling, blue eyes and blond hair, adolescent blistering sunburn (twofold increase in risk), family history of melanoma.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Asymptomatic

• Pigmented lesion with irregular border and variegation in color

• Bleeding, scaling, size, or texture change in any pigmented lesion (ABCDE mnemonic—asymmetry, border irregularity, color variegation, diameter 0.6 mm on back or lower leg [in whites] or hand, feet, and nails [in African Americans], elevation above the skin surface)

DIAGNOSTIC APPROACH

Differential Diagnosis

• Junctional nevus

• Dysplastic nevus

• Malignant melanoma (the risk of malignancy is greatest in nevi that are more than 5 mm in diameter, have irregular borders, are asymmetrical, or have variegated coloration)

• Pigmented basal or squamous cell carcinoma

• Seborrheic keratoses

Associated Conditions: Junctional nevus, dysplastic nevus.

Workup and Evaluation

Laboratory: No evaluation indicated.

Imaging: No imaging indicated, used only to evaluate metastases (brain, bone, lymph nodes).

Special Tests: Excisional biopsy for all vulvar nevi or suspicious nevi anywhere on the body. All lesions should be submitted for histologic examination; they never should be removed destructively.

Diagnostic Procedures: Physical examination and excisional biopsy.

Pathologic Findings

Superficial spreading melanoma (70% of cases), nodular (vertical growth, 15%), acral lentiginous (2% to 8%), lentigo maligna (4% to 10%).

FOLLOW-UP

Patient Monitoring: Frequent (every 3 to 6 months) total body inspection for abnormal or changing nevi. Annual chest radiograph (6% of recurrences diagnosed this way). Weekly self-examination.

Prevention/Avoidance: Avoidance of excessive sun exposure, especially blistering sunburn. Sunscreen use.

Possible Complications: Disease progression or spread, cosmetic damage by excision.

Expected Outcome: Prognosis is based on staging—5-year survival if no local or distant spread, 70%; <0.85-mm thick, 95% to 100%; lymphatic involvement, 5%.

MISCELLANEOUS

Pregnancy Considerations: Although rarely seen in pregnancy, melanoma is exacerbated by this condition. Although any malignant metastasis to the fetus is rare, melanomas represent up to one third of all malignancies found. Melanoma is one of the few malignancies that spreads to the placenta, and metastatic melanoma is a threat to both the fetus and mother. If a woman has had melanoma, it is recommended that she wait 2 or more years before planning a pregnancy.

ICD-9-CM Codes: Based on location and severity of disease.

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