Melanoma: An FP’s guide to diagnosis and management

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doi:10.12788/jfp.0233

Applied Evidence

Melanoma: An FP’s guide to diagnosis and management

J Fam Pract. 2021 July;70(6):271-278 | 10.12788/jfp.0233

By

Wendi Wohltmann, MD, FAAD

Jessica Servey, MD, MHPE, FAAFP

This review details the latest recommendations on dermoscopy and excision techniques, indications for sentinel lymph node biopsy, and Tx options.

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PRACTICE RECOMMENDATIONS

› Consider adding dermoscopy to the physical exam to increase sensitivity and specificity in diagnosing melanoma. A

› Perform wide local excision for invasive cutaneous melanoma: 1-cm margin for tumors up to 1 mm thick; 1 to 2 cm for tumors > 1 mm to 2 mm thick; and 2 cm for tumors > 2 mm thick. A

› Do not hesitate to consider, as needed, hormone replacement therapy or hormonal contraception for women with a prior diagnosis of melanoma, as this form of contraception does not confer an increased risk of melanoma. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

References

1. NIH. Cancer stat facts: melanoma of the skin. 2018. Accessed May 13, 2021. https://seer.cancer.gov/statfacts/html/melan.html

2. Watts CG, Dieng M, Morton RL, et al. Clinical practice guidelines for identification, screening and follow-up of individuals at high risk of primary cutaneous melanoma: a systematic review. Br J Dermatol. 2015;172:33-47.

3. Schadendorf D, van Akkooi ACJ, Berking C, et al. Melanoma. Lancet. 2018;392:971-984.

4. Dinnes J, Deeks JJ, Chuchu N, et al. Dermoscopy, with and without visual inspection, for diagnosing melanoma in adults. Cochrane Database Syst Rev. 2018(12):CD011902.

5. Morris JB, Alfonso SV, Hernandez N, et al. Examining the factors associated with past and present dermoscopy use among family physicians. Dermatol Pract Concept. 2017;7:63-70.

6. Henning JS, Dusza SW, Wang SQ, et al. The CASH (color, architecture, symmetry, and homogeneity) algorithm for dermoscopy. J Am Acad Dermatol. 2007;56:45-52.

7. Rosendahl C, Cameron A, McColl I, et al. Dermatoscopy in routine practice — “chaos and clues”. Aust Fam Physician. 2012;41:482-487.

8. Soyer HP, Argenziano G, Zalaudek I, et al. Three-point checklist of dermoscopy: a new screening method for early detection of melanoma. Dermatology. 2004;208:27-31.

9. Argenziano G, Fabbrocini G, Carli P, et al. Epiluminescence microscopy for the diagnosis of doubtful melanocytic skin lesions. Comparison of the ABCD rule of dermatoscopy and a new 7-point checklist based on pattern analysis. Arch Dermatol. 1998;134:1563-1570.

10. Marghoob AA, Usatine RP, Jaimes N. Dermoscopy for the family physician. Am Fam Physician. 2013;88:441-450.

11. Rogers T, Marino ML, Dusza SW, et al. A clinical aid for detecting skin cancer: the Triage Amalgamated Dermoscopic Algorithm (TADA). J Am Board Fam Med. 2016;29:694-701.

12. Argenziano G, Soyer HP, Chimenti S, et al. Dermoscopy of pigmented skin lesions: results of a consensus meeting via the Internet. J Am Acad Dermatol. 2003;48:679-93.

13. Carli P, Quercioli E, Sestini S, et al. Pattern analysis, not simplified algorithms, is the most reliable method for teaching dermoscopy for melanoma diagnosis to residents in dermatology. Br J Dermatol. 2003;148:981-984.

14. Yélamos O, Braun RP, Liopyris K, et al. Usefulness of dermoscopy to improve the clinical and histopathologic diagnosis of skin cancers. J Am Acad Dermatol. 2019;80:365-377.

15. Westerhoff K, McCarthy WH, Menzies SW. Increase in the sensitivity for melanoma diagnosis by primary care physicians using skin surface microscopy. Br J Dermatol. 2000;143:1016-1020.

16. Vestergaard ME, Macaskill P, Holt PE, et al. Dermoscopy compared with naked eye examination for the diagnosis of primary melanoma: a meta-analysis of studies performed in a clinical setting. Br J Dermatol. 2008;159:669-676.

17. Usatine RP, Shama LK, Marghoob AA, et al. Dermoscopy in family medicine: a primer. J Fam Pract. 2018;67:E1-E11.

18. Swetter SM, Tsao H, Bichakjian CK, et al. Guidelines of care for the management of primary cutaneous melanoma. J Am Acad Dermatol. 2019;80:208-250.

19. Seiverling EV, Ahrns HT, Bacik LC, et al. Biopsies for skin cancer detection: dispelling the myths. J Fam Pract. 2018;67:270-274.

20. Martin RCG, Scoggins CR, Ross MI, et al. Is incisional biopsy of melanoma harmful? Am J Surg. 2005;190:913-917.

21. Mir M, Chan CS, Khan F, et al. The rate of melanoma transection with various biopsy techniques and the influence of tumor transection on patient survival. J Am Acad Dermatol. 2013;68:452-458.

22. Breslow A. Thickness, cross-sectional areas and depth of invasion in the prognosis of cutaneous melanoma. Ann Surg. 1970;172:902-908

23. Gershenwald JE, Scolyer RA, Hess KR, et al. Melanoma staging: evidence-based changes in the American Joint Committee on Cancer 8th ed cancer staging manual. CA Cancer J Clin. 2017;67:472-492.

24. Morton DL, Thompson JF, Cochran AJ, et al. Final trial report of sentinel-node biopsy versus nodal observation in melanoma. N Engl J Med. 2014;370:599-609.

25. Valsecchi ME, Silbermins D, de Rosa N, et al. Lymphatic mapping and sentinel lymph node biopsy in patients with melanoma: a meta-analysis. J Clin Oncol. 2011;29:1479-1487.

26. Memorial Sloan Kettering Cancer Center. Risk of sentinel lymph node metastasis nomogram. Accessed May 13, 2021. www.mskcc.org/nomograms/melanoma/sentinel_lymph_node_metastasis

27. Gershenwald JE, Scolyer RA, Hess KR, et al. Melanoma of the skin. In: Amin MB, Edge SB, Greene FL, eds. AJCC Cancer Staging Manual. 8th ed. Springer International Publishing; 2017:563-581.

28. Xing Y, Bronstein Y, Ross MI, et al. Contemporary diagnostic imaging modalities for the staging and surveillance of melanoma patients: a meta-analysis. J Natl Cancer Inst. 2011;103:129-142.

29. Tsao H, Feldman M, Fullerton JE, et al. Early detection of asymptomatic pulmonary melanoma metastases by routine chest radiographs is not associated with improved survival. Arch Dermatol. 2004;140:67-70.

30. Wang TS, Johnson TM, Cascade PN, et al. Evaluation of staging chest radiographs and serum lactate dehydrogenase for localized melanoma. J Am Acad Dermatol. 2004;51:399-405.

31. Yancovitz M, Finelt N, Warycha MA, et al. Role of radiologic imaging at the time of initial diagnosis of stage T1b-T3b melanoma. Cancer. 2007; 110:1107-1114.

32. Swetter SM, Thompson JA, Albertini MR, et al. NCCN Guidelines: cutaneous melanoma, version 4.2020. Accessed June 7, 2021. http://medi-guide.meditool.cn/ymtpdf/ACC90A18-6CDF-9443-BF3F-E29394D495E8.pdf

33. Stensheim H, Møller B, van Dijk T, et al. Cause-specific survival for women diagnosed with cancer during pregnancy or lactation: a registry-based cohort study. J Clin Oncol. 2009;27:45-51.

34. Lens MB, Rosdahl I, Ahlbom A, et al. Effect of pregnancy on survival in women with cutaneous malignant melanoma. J Clin Oncol. 2004;22:4369-4375.

35. Gandini S, Iodice S, Koomen E, et al. Hormonal and reproductive factors in relation to melanoma in women: current review and meta-analysis. Eur J Cancer. 2011;47:2607-2617.

36. Byrom L, Olsen CM, Knight L, et al. Does pregnancy after a diagnosis of melanoma affect prognosis? Systematic review and meta-analysis. Dermatol Surg. 2015;41:875-882.

37. Tang JY, Spaunhurst KM, Chlebowski RT, et al. Menopausal hormone therapy and risks of melanoma and nonmelanoma skin cancers: women’s health initiative randomized trials. J Natl Cancer Inst. 2011;103:1469-1475.

38. Carlos G, Anforth R, Clements A, et al. Cutaneous toxic effects of BRAF inhibitors alone and in combination with MEK inhibitors for metastatic melanoma. JAMA Dermatol. 2015;151:1103-1109.

39. Macdonald JB, Macdonald B, Golitz LE, et al. Cutaneous adverse effects of targeted therapies: part I: inhibitors of the cellular membrane. J Am Acad Dermatol. 2015;72:203-218.

40. Welsh SJ, Corrie PG. Management of BRAF and MEK inhibitor toxicities in patients with metastatic melanoma. Ther Adv Med Oncol. 2015;7:122-136.

41. Kandolf Sekulovic L, Peris K, Hauschild A, et al. More than 5000 patients with metastatic melanoma in Europe per year do not have access to recommended first-line innovative treatments. Eur J Cancer. 2017;75:313-322.

42. Long GV, Grob JJ, Nathan P, et al. Factors predictive of response, disease progression, and overall survival after dabrafenib and trametinib combination treatment: a pooled analysis of individual patient data from randomised trials. Lancet Oncol. 2016;17:1743-1754.

43. Che G, Huang B, Xie Z, et al. Trends in incidence and survival in patients with melanoma, 1974-2013. Am J Cancer Res. 2019;9:1396-1414.

44. Lyth J, Falk M, Maroti M, et al. Prognostic risk factors of first recurrence in patients with primary stages I–II cutaneous malignant melanoma – from the population‐based Swedish melanoma register. J Eur Acad Dermatol Venereol. 2017;31:1468-1474.

45. Robinson JK, Wayne JD, Martini MC, et al. Early detection of new melanomas by patients with melanoma and their partners using a structured skin self-examination skills training intervention: a randomized clinical trial. JAMA Dermatol. 2016;152:979-985.

46. Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for skin cancer: US Preventive Services Task Force recommendation statement. JAMA. 2016;316:429-435.

47. Gardner LJ, Strunck JL, Wu YP, et al. Current controversies in early-stage melanoma: questions on incidence, screening, and histologic regression. J Am Acad Dermatol. 2019;80:1-12.

48. Wei EX, Qureshi AA, Han J, et al. Trends in the diagnosis and clinical features of melanoma in situ (MIS) in US men and women: a prospective, observational study. J Am Acad Dermatol. 2016;75:698-705.

49. Linos E, Swetter SM, Cockburn MG, et al. Increasing burden of melanoma in the United States. J Invest Dermatol. 2009;129:1666-1674.

50. Curchin DJ, Forward E, Dickison P, et al. The acceleration of melanoma in situ: a population-based study of melanoma incidence trends from Victoria, Australia, 1985-2015. J Am Acad Dermatol. 2019;80:1791-1793.

51. Dennis LK. Analysis of the melanoma epidemic, both apparent and real: data from the 1973 through 1994 surveillance, epidemiology, and end results program registry. Arch Dermatol. 1999;135:275-280.

52. Jemal A, Saraiya M, Patel P, et al. Recent trends in cutaneous melanoma incidence and death rates in the United States, 1992-2006. J Am Acad Dermatol. 2011;65:S17-S25.

CASE

A 48-year-old man comes to your clinic with a dark nevus on his right upper arm that appeared 2 months earlier. He says that the lesion has continued to grow and has bled (he thought because he initially picked at it). On exam, there is a 7-mm brown papule with 2 black dots and slightly asymmetric borders.

How would you proceed with this patient?

Melanoma is the fifth leading cause of new cancer cases annually, with > 96,000 new cases in 2019.¹ Overall, melanoma is more common in men and in Whites, with 48% diagnosed in people ages 55 to 74.¹ The past 2 decades have seen numerous developments in the diagnosis, treatment, and surveillance of melanoma. This article covers recommendations, controversies, and issues that require future study. It does not cover uveal or mucosal melanoma.

Evaluating a patient with a new or changing nevus

Known risk factors for melanoma include a changing nevus, indoor tanning, older age, many melanocytic nevi, history of a dysplastic nevus or of blistering sunburns during teen years, red or blonde hair, large congenital nevus, Fitzpatrick skin type I or II, high socioeconomic status, personal or family history of melanoma, and intermittent high-intensity sun exposure.^2-3 Presence of 1 or more of these risk factors should lower the threshold for biopsy.

Worrisome physical exam features (FIGURE) are nevus asymmetry, irregular borders, variegated color, and a diameter > 6 mm (the size of a pencil eraser). Inquire as to whether the nevus’ appearance has evolved and if it has bled without trauma. In a patient with multiple nevi, 1 nevus that looks different than the rest (the so-called “ugly duckling”) is concerning. Accuracy of diagnosis is enhanced with dermoscopy. A Cochrane review showed that skilled use of dermoscopy, in addition to inspection with the naked eye, considerably increases the sensitivity and specificity of diagnosing melanoma.⁴ Yet a 2017 study of 705 US primary care practitioners showed that only 8.3% of them used dermoscopy to evaluate pigmented lesions.⁵

Several published algorithms and checklists can aid clinicians in identifying lesions suggestive of melanoma—eg, ABCDE, CASH, Menzies method, “chaos and clues,” and 2-step and 3- and 7-point checklists.^6-10 A simple 3-step algorithm, the TADA (triage amalgamated dermoscopic algorithm) method is available to novice dermoscopy users.¹¹ Experts in pigmented lesions prefer to use pattern analysis, which requires simultaneously assessing multiple lesion patterns that vary according to body site.^12,13

Dermoscopic features suggesting melanoma are atypical pigment networks, pseudopods, radial streaking, irregular dots or globules, blue-whitish veil, and granularity or peppering.¹⁴ Appropriate and effective use of dermoscopy requires training.^15,16 Available methods for learning dermoscopy include online and in-person courses, mentoring by experienced dermoscopists, books and articles, and free apps and online resources.¹⁷

Continue to: Perform a skin biopsy, but do this first