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DIAGNOSIS
Suspicious lesions are assessed by examining the entire skin surface including nevi
ABCDE mnemonic is utilized in characterizing lesions, eg asymmetry, border irregularities, color changes, diameter & evolution
“Ugly duckling” concept: Melanotic lesions have a different appearance from the surrounding nevi
Dermoscopy
A noninvasive technique using a magnifying device to visualize diagnostic features of pigmented lesion
Enhances diagnostic accuracy & leads to performance of a biopsy
Biopsy
A full-thickness, narrow, excisional biopsy should be the basis of diagnosis
Wide surgical margins may affect accuracy of succeeding lymphatic mapping
An experienced pathologist should examine the specimen for microstaging [a staging technique determined histologically by the Breslow classification (vertical thickness of lesion) & the Clark classification (anatomic level of invasion)]
Various biopsy methods exist, eg incisional, punch, elliptical or broad shave; however, chosen method should be able to obtain an adequate specimen for a definitive diagnosis or exclusion of melanoma
Partial sampling or incisional biopsy can be performed on facial, acral, or large lesions & in uncertain diagnosis or low clinical suspicion
Broad shave biopsy for lentigo maligna melanoma in situ
Fine-needle aspiration may be done for confirmation of lymph node involvement in stage III & IV disease & of initial clinical recurrence
Pathology report should include the maximum histologic depth of lesion (Breslow thickness), ulceration, Clark level (optional for tumors >1 mm), mitotic rate, & peripheral & deep margins
Other histologic features reported include satellitosis, vertical growth phase, tumor-infiltrating lymphocytes, dermal regression, angiolymphatic invasion, histologic subtypes, neurotropism, & desmoplasia
Repeat biopsy may be performed if specimen was inadequate for diagnosis or microstaging
Alternative Diagnosis
Several diseases may present similarly as melanoma & thus have to be excluded: Atypical moles, blue nevi, venous lakes, seborrheic keratoses, warts w/ focal thromboses, basal & squamous cell carcinomas, dermatofibromas, hematomas, & pyogenic granulomas
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MELANOMA CANCER STAGING
Preliminary workup includes a thorough medical history & physical examination
A detailed history should include an evaluation of melanoma-related risk factors & review of systems paying attention to skin, lymphatic, neurologic, pulmonary, gastrointestinal, & musculoskeletal systems
Physical examination (PE) should be focused on a complete examination of the skin & lymph nodes
Staging studies may include lab tests (CBC, LDH, liver function tests) & imaging procedures (chest x-ray, CT & PET scans, MRI, & nodal ultrasound)
In asymptomatic patients w/ newly diagnosed melanoma of any thickness, baseline lab tests & imaging studies are generally not advised; may be performed if clinically indicated based on patient’s signs & symptoms
Workup is unnecessary in low-risk melanoma; however, imaging is recommended in higher stages of melanoma for proper staging
Baseline imaging may be considered if sentinel lymph node biopsy is positive, recommended in clinically positive nodes and in-transit metastases or recurrence
Ultrasound of the nodal basin may be considered if PE of regional LN is uncertain; histologic confirmation should be done if w/ abnormal results
Genetic mutation testing may be performed if targeted therapy is being considered for the patient or if it is pertinent for candidacy in clinical trials
Routine genetic testing is not encouraged on primary localized melanomas
Sentinel Lymph Node Biopsy (SLNB)
A minimally invasive microstaging technique that has become a staging standard for cutaneous melanoma
Considered the most specific & sensitive staging technique for detection of micrometastases in LN
Performance of SLNB may depend on presence of comorbidities or patient preference
Biopsies the node that immediately drains the primary tumor
Identifies nodal metastasis
Identifies patients who may need lymph node dissection & patients who may gain from adjuvant therapy
Should be done before wide excision of the lesion for accurate lymphatic mapping
Not recommended for melanoma in situ or T1a melanoma
Generally not considered w/ tumor thickness
<
0.75 mm, though it may be done in high-risk patients or if microstaging result is uncertain
Should be discussed w/ patient if tumor thickness is 0.76-1 mm
Recommended in intermediate-thickness (1-4 mm) & thick (>4 mm) melanomas
TNM Classification
Developed by the American Joint Committee on Cancer (AJCC)
It details tumor thickness, degree of lymph node involvement, & metastatic spread
Information provided helps determine treatment, follow-up, & prognosis of patient
Based on the 2010 American Joint Committee on Cancer TNM definitions for melanoma
Primary Tumor (T)
TX: Primary tumor unassessable
T0: No evidence of primary tumor
Tis : : Melanoma in situ
T1a: <1.0 mm thickness w/o ulceration & <1 mitosis/mm
2
T1b: <1.0 mm thickness w/ ulceration or ≥1 mitosis/mm
2
T2a: 1.01-2.0 mm thickness w/o ulceration
T2b: 1.01-2.0 mm thickness w/ ulceration
T3a: 2.01-4.0 mm thickness w/o ulceration
T3b: 2.01-4.0 mm thickness w/ ulceration
T4a: >4.0 mm thickness w/o ulceration
T4b: >4.0 mm thickness w/ ulceration
Regional Lymph Nodes (N)
NX: Regional lymph nodes unassessable
N0: No detectable regional metastases
N1a: 1 metastatic node w/ micrometastasis
1
N1b: 1 metastatic node w/ macrometastasis
2
N2a: 2-3 metastatic nodes w/ micrometastasis
1
N2b: 2-3 metastatic nodes w/ macrometastasis
2
N2c: 2-3 metastatic nodes w/ in-transit metastases/satellites w/o metastatic nodes
N3: ≥4 metastatic nodes, or matted nodes, or in-transit metastases/satellites w/ metastatic nodes
Distant Metastasis (M)
M0: No distant metastasis
M1a: Distant skin, subcutaneous, or nodal metastases w/ normal serum LDH
M1b: Lung metastases w/ normal serum LDH
M1c: All other visceral metastases w/ normal serum LDH or any distant metastases w/ elevated serum LDH
Based on the 2010 American Joint Committee on Cancer Anatomic Stage and Prognostic Groups
Clinical Staging
3
Stage 0:
Tis N0 M0
Stage IA:
T1a N0 M0
Stage IB:
T1b N0 M0; T2a N0 M0
Stage IIA:
T2b N0 M0; T3a N0 M0
Stage IIB:
T3b N0 M0; T4a N0 M0
Stage IIC:
T4b N0 M0
Stage III:
Any T >N1 M0
Stage IV:
Any T Any N M1
Pathologic Staging
4
Stage 0
Tis N0 M0
Stage IA
T1a N0 M0
Stage IB
T1b N0 M0; T2a N0 M0
Stage IIA
T2b N0 M0 T3a; N0 M0
Stage IIB
T3b N0 M0 T4a; N0 M0
Stage IIC
T4b N0 M0
Stage IIIA
T1-4a N1a M0
T1-4a N2a M0
Stage IIIB
T1-4b N1a M0
T1-4b N2a M0
T1-4a N1b M0
T1-4a N2b M0
T1-4a N2c M0
Stage IIIC
T1-4b N1b M0
T1-4b N2b M0
T1-4b N2c M0
Any T N3 M0
Stage IV
Any T Any N M1
1
Micrometastasis is diagnosed after biopsy of sentinel lymph node (SLN)
2
Macrometastasis is defined as nodal metastasis detected clinically & confirmed pathologically
3
Clinical staging includes primary melanoma microstaging & clinical &/or radiologic metastatic evaluation
4
Pathologic staging includes primary melanoma microstaging & regional LN pathologic information after partial or total lymphadenectomy
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