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

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References

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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.

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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.

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Patients who have clinical Stage I or II disease (TABLE 1²⁷) and a negative review of systems and lymph node exam do not require baseline laboratory or radiology tests.^18,28-31 Ultrasonography of the lymph node basin is recommended for any Stage I or II patient with an equivocal lymph node exam.^27,32 Stage III disease warrants computed tomography of the chest, abdomen, and pelvis, and possibly magnetic resonance imaging (MRI) of the brain. For Stage IV, brain MRI is recommended in all patients. Patients with higher risk disease (IIB - IV) will need consultation with Medical Oncology. The surgery and oncology team will make decisions regarding SLNB, genetic testing, and chemotherapy.

Melanoma in women: Considerations to keep in mind

Hormonal influences of pregnancy, lactation, contraception, and menopause introduce special considerations regarding melanoma, which is the most common cancer occurring during pregnancy, accounting for 31% of new malignancies.³³ Risk of melanoma lessens, however, for women who first give birth at a younger age or who have had > 5 live births.^18,34,35 There is no evidence that nevi darken during pregnancy, although nevi on the breast and abdomen may seem to enlarge due to skin stretching.¹⁸ All changing nevi in pregnancy warrant an examination, preferably with dermoscopy, and patients should be offered biopsy if there are any nevus characteristics associated with melanoma.¹⁸

One benefit of the family physician performing the initial biopsy is that a confirmed melanoma diagnosis will almost certainly get an expedited dermatology appointment.

The effect of pregnancy on an existing melanoma is not fully understood, but evidence from controlled studies shows no negative effect. Recent working group guidelines advise WE with local anesthesia without delay in pregnant patients.¹⁸ Definitive treatment after melanoma diagnosis should take a multidisciplinary approach involving obstetric care coordinated with Dermatology, Surgery, and Medical Oncology.¹⁸

Most recommendations on the timing of pregnancy following a melanoma diagnosis have limited evidence. One meta-analysis concluded that pregnancy occurring after successful treatment of melanoma did not change a woman’s prognosis.³⁶ Current guidelines do not recommend delaying future pregnancy if a woman had an early-stage melanoma. For melanomas deemed higher risk, a woman could consider a 2- to 3-year delay in the next planned pregnancy, owing to current data on recurrence rates.¹⁸

A systematic review of women who used hormonal contraception or postmenopausal hormone replacement therapy (HRT) showed no associated increased risk of melanoma.³⁵ An additional randomized trial showed no effect of HRT on melanoma risk.³⁷

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