• 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
• 3-fold increase in the incidence of melanoma in the United States in the past decade
• Risk factors include:
-Multiple or dysplastic nevi
-First sunburn at an early age
-Reddish or blond hair
-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
• Lesions that are suspicious for melanoma can be identified by their clinical characteristics:
• Other clinical signs of melanoma include:
• Lymphadenopathy may be present in regional lymph node basins
• 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
• Synchronous melanoma lesions
• In-transit melanoma metastases
• Evidence of regional lymphadenopathy
• Nonmelanotic skin cancer
• 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)
• 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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