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  • • Predominately a disease of fair-skinned people

    • Only 15% of melanomas develop in preexisting nevi, the remainder arise de novo

    • Most important prognostic factors include:

    • -Vertical height of melanoma

      -Sentinel lymph node status

      -Number of positive lymph nodes

      -Presence of metastatic disease

    • Melanoma typically metastasizes by the lymphatic route in a predictable and orderly fashion

    • 4 histologic categories of melanoma:

    • -Superficial spreading, 70% of cases

      -Nodular melanoma, 15% of cases

      -Lentigo maligna melanoma, 4-10% of cases

      -Acral lentiginous melanoma, 2-8% of cases

    • Melanoma most commonly metastasizes to the lungs, liver, and brain but can also involve the bone, adrenals, heart, and bowel

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Epidemiology

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  • • 3-fold increase in the incidence of melanoma in the United States in the past decade

    • Risk factors include:

    • -UV exposure

      -Multiple or dysplastic nevi

      -First sunburn at an early age

      -Freckles

      -Fair complexion

      -Reddish or blond hair

      -Blue eyes

      -First-degree relative with melanoma

    • 90% of melanomas are cutaneous lesions, while the remainder occurs in the pigmented cells of the retina, or the mucous membranes of the nasopharynx, vulva, and anal canal

    • 2% of melanomas present as metastatic disease to regional lymph nodes or distant sites without a known primary

    • 10% of melanomas occur in patients with familial dysplastic nevi syndrome

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Symptoms and Signs

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  • • Lesions that are suspicious for melanoma can be identified by their clinical characteristics:

    • -Asymmetry

      -Border irregularity

      -Color (variable or dark pigmentation)

      -Diameter (> 6 mm)

    • Other clinical signs of melanoma include:

    • -Itching

      -Bleeding

      -Ulceration

      -Changes in a preexisting benign mole

    • Lymphadenopathy may be present in regional lymph node basins

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Imaging Findings

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  • CT or MRI: Most useful to detect metastatic disease, or in the evaluation of noncutaneous melanomas

    PET scan: May demonstrate areas of metastatic disease not detected with conventional CT or MRI

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  • • Melanoma

    • Dysplastic nevi

    • Benign mole

    • Nonmelanotic skin cancer:

    • -Basal cell carcinoma

      -Squamous cell carcinoma

      -Merkel cell carcinoma

      -Dermatofibrosarcoma protuberans

      -Sarcomas

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Rule Out

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  • • Synchronous melanoma lesions

    • In-transit melanoma metastases

    • Evidence of regional lymphadenopathy

    • Nonmelanotic skin cancer

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  • • Complete history with emphasis on risk factors

    • Thorough physical exam including regional lymph node basin assessment

    • Excisional biopsy (1-2 mm margins) or punch biopsy of the suspicious lesion

    • Fine-needle aspiration of palpable lymph nodes suspected of representing melanoma metastases

    • Chest film to evaluate for evidence of pulmonary metastases

    • Obtain more thorough radiographic evaluation (head, chest and/or abdominal CT) in high-risk patients that present with bulky lymph node metastatic disease (clinical stage III)

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When to Refer

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  • • All patients diagnosed with melanoma should be evaluated by a dermatologist to assess for synchronous melanomas or other atypical nevi

    • Patients with lymph node or regional metastases should be evaluated by a medical oncologist for consideration ...

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