Nov 7, 2008 - Referral of high-risk patients to a dermatologist or melanoma clinic for surveillance is appropriate. PROG
of the risk factors for m elanom a. M elanom a m ay be found opportunistically during clinical exam other indications. In the absence of any substantial evidence as to its effectiveness in reducing m m elanom a, population-based skin screening cannot be recom m ended.
Patients w ho note disturbing skin lesions are frequently in a better position to observe changes a sym ptom s of skinMelanoma lesions than their doctors. If a patient expresses concern about a particular les - An Aide Memoire to Assist Diagnosis reassurance should only w hen doubt nature of the lesion. If there M e labe n o given ma - A n A id e M ethere m o iris e no to A s s is t about D ia g nthe o s is The aim of early detection of melanoma is to improve the cure rate of people who present with a melanoma. doubt, repeat observation after one to three m onths is essential.
The doctor aofis first is cure the key early diagnosis. ofa.any The aimgeneral of earlypractitioner detection ofas m elanom to imcontact prove the rate to of people w ho presentInwthe ith aabsence m elanom substantial evidence as to its effectiveness inis reducing mortality from melanoma, population-based skin The general practitioner as doctor of first contact the key to early diagnosis. To help diagnose m elanom Surgical excision biopsy w ith a 2 m m m argin is the procedure of choice if any signsa suggestive of screening cannot be recommended. To help diagnose melanoma early the general practitioner needs early the general practitioner needs to have appropriate observational and diagnostic skills and an aw areness to mhave elanom a areforpresent. Partial biopsies i.e. shave punch biopsies n o t for appropriate except w appropriate observational diagnostic skills and anorawareness of the clinical riskare factors melanoma. of the risk factors m elanom a. Mand elanom a m ay be found opportunistically during exam ination for Melanoma may be found opportunistically during clinical examination for other indications. biopsy is not possible. Locally advanced m elanom a w hen recognised, is best referred for speciali other indications. In the absence of any substantial evidence as to its effectiveness in reducing m ortality from m elanom a, population-based skin screening cannot be recom m ended. w ithout biopsy. Patients who note disturbing skin lesions are frequently in a better position to observe changes and Patients w ho note disturbing are frequently a betterexpresses position toconcern observeabout changes and symptoms of skin lesions skin thanlesions their doctors. If theinpatient a particular lesion, PRACTI CE POI NTS sym ptom s of skin lesions than their doctors. If a patient expresses concern about a particular lesion, reassurance should be given only when there is no doubt about the nature of the lesion. If there is any reassurance should be given only hen to there is no doubt about the nature of the excision lesion. If biopsy there iswith any a 2 mm doubt, repeat observation afterwone three months is essential. Surgical • The history of a skin lesion is very im portant. A history of change in size, shape or colour doubt, repeat observation after one to three m onths is essential. margin is the treatment of choice if any signs suggestive of early melanoma are present. Partial biopsies i.e. im portant cluearetonot theappropriate diagnosis of mwhen elanom a. Intermisittent itch is som etim es a sym ptom . shave or punch biopsies except excision notsuggestive possible. Locally procedure Surgical excision biopsy w ith a 2 m m m argin is the of choicebiopsy if any signs of earlyadvanced melanoma recognised isand best indicate referred foran specialist care without are rare advanced mare elanom a. m elanom ableeding arewhen present. Partial biopsies i.e. shave or punch biopsies n obiopsy. t appropriate except w hen excision biopsy is not possible. Locally advanced m elanom a w hen recognised, is best referred for specialist care • biopsy. Physical exam ination should assess the skin surface w ith high-quality illum ination PRACTICE POINTS w ithout
to dete w hich the patient is unaw are. M elanom a seldom resem bles other pigm ented skin lesions x CE ThePOI history of a skin lesion is very important. A history of change in size, shape or colour is an PRACTI “ ugly NTS duckling” important clue to the. diagnosis of melanoma. Intermittent itch is sometimes a symptom. Pain and/or •
The history are of arare skinand lesion is very portant. melanoma. A history of change in size, shape or colour is an bleeding indicate anim advanced Not allclue m elanom as areofblack - variation in colour andetim m ultiple e.g. brow n, tan, pin im portant to the diagnosis m elanom a. Interm ittent itch is som es a symcolours ptom . Pain and/or x bleeding Physical examination should the skin surface high-quality they illumination to detect lesions of of depigm entation areanassess often indicators of m alignancy; are frequently present in m ela are rare and indicate advanced m elanom a. with which the patient is unaware. Melanoma seldom resembles other pigmented skin lesions - it is an are useful in clinical • Physical exam ination should diagnosis. assess the skin surface w ith high-quality illum ination to detect lesions of “ugly duckling”. w hich the patient is unaw are. M elanom a seldom resem bles other pigm ented skin lesions - it is an •x “ ugly Forduckling” suspicious lesions, on the level of the biopsy or and referral Not all melanomas are black - depending variation in colour and skill multiple colours e.g.GP, brown, tan, pink areas should be . of depigmentation are useful indicators of malignancy; they are frequently present and are clinically period ofasobservation (preferably to tw o m onths, forpink a mand axim um of three m • • NotAall m elanom are black - variation in colour for and one m ultiple colours e.g. browbut n, tan, areas useful. of be depigm entation are often indicators of m alignancy; they are frequently present in m elanom a and appropriate for clinically doubtful pigm ented skin lesions. When w aiting for the longe useful in clinical diagnosis. x areFor suspicious lesions, depending on the skill level of the GP, biopsy or referral should be considered.
•
photography of the lesion is recom m ended to be used as a baseline to observe/com pare
• x ForA suspicious lesions, depending the level of months the GP, biopsy or referral should be considered. period of three observation (preferably for skill onepatients to two butwfor a but maximum of three months) may are obvio over the m onths – wonarning not to ait, to seek review if there be appropriate for clinically doubtful pigmented skin lesions. When waiting for the longermperiod • A period of observation (preferably for one to tw o m onths, but for a m axim um of three m onths) ay before the of threelesion m onths. Another toapproach is baseline to use to a derm oscopy im age capture device is recommended be used as a When observe/compare any changes bephotography appropriate for the clinically doubtful pigm ented skin lesions. w aiting for the longer period, change over this tim e. mpatients over the three months –iswarning wait, to seektoreview if therepare are any changes before photography of the lesion recom ended tonot be to used as but a baseline observe/com changes thethe three months. approach to to use a dermoscopy image capture device to detect change over three m onthsAnother – w arning patientsisnot w ait, but to seek review if there are obvious changes • over Locally advanced m elanom a should be referred to a specialist surgeon or w here possible thisthree time.m onths. Another approach is to use a derm oscopy im age capture device to detect before the specialist mtim elanom a clinic, w ithout biopsy. change over this e. x Locally advanced melanoma should be referred to a specialist surgeon or where possible, to a • Locally advanced m elanom a should referred to a specialist surgeon or w here possible, to a specialist melanoma clinic, withoutbebiopsy. CLINICAL DIAGNOSI S w ithout biopsy. specialist m elanom a clinic,
General practitioners CLINICAL DIAGNOSI S should CLINICAL DIAGNOSIS
be aware of the appearance and clinical types of melanoma. In most cas diagnosis of melanoma is based onappearance the ABCDE method of clinical diagnosis: General practitioners should be aware of the and clinical types oftypes melanoma. In most cases the cases the General practitioners should be aware of the appearance and clinical of melanoma. In most Aasymmetry diagnosis of melanoma is based on the ABCDE method of clinical diagnosis: diagnosis of melanoma is based on the ABCDE method of clinical diagnosis: Aasymmetry B-Aborder irregularity asymmetry Bborder irregularity border irregularity C-B-colour variation NB - black is not essential and may not be present in some melanomas, eg. amelan C- Ccolour variation NBNB - black is not essential and may notnot bebe present in in some melanomas, eg.ie. amelanotic colour variation - black is not essential and may present some melanomas, nodular oror some nodular melanomas nodular melanomas amelanotic melanoma D-Ddiameter greater 6 However mm. melanoma However melanoma can be less diagnosed when less than this diameter Ddiameter greater than 6than mm. However can bebe diagnosed when than this diameter diameter greater than 6 mm. melanoma can diagnosed when less than this diameter Eevolution and/or elevation eg. lesions may enlarge and a flat lesion may become raised in a matter a few E-E-evolution and/or elevation eg. lesions may enlarge flat become lesion raised may become raised in a matter evolution and /or elevation e.g. lesions may enlarge and a flat and lesionamay in a of matter of a few weeks. weeks. weeks.
The bottom line is that general practitioners should strongly consider excision of lesions that are unusual, new, Thebottom bottom line istois that general practitioners should strongly excision for lesions that are The line that general practitioners shouldconsider strongly consider excision ofunusual, lesionsnew, that are unus changing or difficult diagnose. changing or difficult to diagnose. changing or difficult to diagnose. Many melanomas will be diagnosed by the patient in the general observation of their own body. All patients and especially those at high be encouraged to undertake regular self examination mirror Many melanomas willrisk be should diagnosed by the patient in the general observation of theirusing own abody. Allorpatients and Many melanomas willinrisk be diagnosed byadvised the patient in theregular general ofontheir ownorbody. All pa involving a partner theshould processbe andencouraged be to be suspicious of newself or observation changing lesions the skin. especially those or at carer high to undertake examination using a mirror especially highinrisk be be encouraged undertake regular self examination using a mirro involving a those partner at or carer the should process and advised to beto suspicious of new or changing lesions on the skin. T his aide-m em oire has been developed to as s ist the diagnostic process and help im prove
involving a partner or carer in the process andentbe advised the outcom e of clinical m anagem of m elanom a. to be suspicious of new or changing lesions T his aide-m em oire has been developed to as s ist the diagnostic process and help im prove thebeen outcom e oftoclinical mdiagnostic anagemprocess ent of m elanom a. This aide-memoire has developed assist the 4HISåAIDE MEMOIREåHASåBEENåDEVELOPEDåTOåASSISTåTHEåDIAGNOSTICåPROCESS and help improve the outcome of clinical management of melanoma. ANDåHELPåIMPROVEåTHEåOUTCOMEåOFåCLINICALåMANAGEMENTåOFåMELANOMA
CLINICAL APPEARANCE Some typical melanomas are shown below:
CLINICAL APPEARANCE Some typical melanomas are shown below:
Acral Melanoma with large amelanotic Early Melanoma Melanoma - Early -- Early Melanoma component (AM) (Flat phase) (Flat phase) M elanom a - E arly (Flat phas e)
L entigo M aligna M elanom a (LM M )
Subungual Melanoma
S uperficial S preading M elanom a (S S M )
A cral M ela nom a w ith large am elanotic com ponent (A M )
Superficial Spreading Superficial Spreading Melanoma Superficial Superficial Spreading Spreading “Ugly Duckling” (with an amelanotic nodular
Lentigo Maligna Melanoma (LMM) Superficial Superficial Spreading Spreading Superficial Spreading Melanoma (SSM) Melanoma (SSM)
S uperficial S preading M elanom a (w ith an am elanotic nodular com ponent)
S ubungual M elanom a
Melanoma Melanoma Melanoma (with (with an (withan an A m ela notic m ela nom a component) amelanotic amelanotic nodular nodular component) c
“ U gly Duckling”
L entigo M aligna (L M )
N odular M elanom a
LentigoMaligna Maligna (LM) Lentigo Amelanotic melanoma Nodular Melanoma
DERMOSCOPY Skin surface microscopy, dermoscopy, is very useful as an aid in the diagnosis of pigmented skin lesions. Dermoscopy represents a form of in vivo microscopy of the epidermis and upper dermis. The technique UNUSUAL VARIANTS allows the melanocyte network and melanin pigment to be visualized. General practitioners are encouraged UNUSUAL VARIANTS toAtypical learn this technique facilitatecause accurate melanoma diagnosis, and those who decide number to use itofshould melanoma is atocommon of misdiagnosis and results in a disproportionate deaths participate in regular training to maintain adequate skills. Biopsy rates can be reduced with appropriate Atypical melanoma isMelanoma a common cause of misdiagnosis and results inmelanoma", a disproportionate number of deaths from melanoma. without pigment, "amelanotic can be a problem because of the training and from melanoma. Melanoma without pigment, "amelanotic melanoma",This can diagnosis be a problem because of in themind for any absence of experience. one of the usual diagnostic criteria (pigmentation). must be kept absence of one of the usual diagnostic criterianodule (pigmentation). This diagnosis must be kept in mind for anyof choice. persistent, enlarging or rapidly growing on the skin and excision biopsy is the treatment persistent, enlarging or rapidly growing nodule on the skin and excision biopsy is the diagnostic method of choice. Nodular melanoma (NM) is usually a firm, raised, uniformly coloured and frequently non-pigmented nodule, Nodular melanoma and (NM)becoming is usually a more firm, raised, uniformly coloured frequently non-pigmented nodule, that is enlarging raised. It accounts forand about 15% of melanomas but comprises more that is60% enlarging and becoming more raised. It accounts for about 15% of melanomas but comprises more than of melanomas >3mm in thickness. than 60% of melanomas >3mm in thickness. DERMOSCOPY Skin surface microscopy, dermoscopy, is very useful as an aid in the diagnosis of pigmented skin lesions. Dermoscopy represents a form of in vivo microscopy of the epidermis and upper dermis. The technique allows the melanocyte network and melanin pigment to be visualized. General practitioners are encouraged to learn this technique to facilitate accurate melanoma diagnosis, and those who decide to use it should participate in regular training to maintain adequate skills. Biopsy rates can be reduced with appropriate Dermoscope Dermoscope Melanoma Melanoma: Dermoscopy training and experience. image (utilizes liquid at skin interface)
(utilizes cross polarized light)
Melanoma
Superficial Spreading Amelanotic melanoma Nodular Melanoma Amelanotic Melanoma Nodular Melanoma Amelanotic melanoma Nodular Melanoma Superficial Spreading
UNUSUAL UNUSUAL VARIANTS VARIANTS
Atypical number ofof deaths Atypical melanoma melanomaisisaacommon commoncause causeofofmisdiagnosis misdiagnosisand andresults resultsinina adisproportionate disproportionate number deaths from of of thethe from melanoma. melanoma. Melanoma Melanomawithout withoutpigment, pigment,"amelanotic "amelanoticmelanoma", melanoma",can canbebea aproblem problembecause because absence kept in in mind forfor any absence of of one oneof ofthe theusual usualdiagnostic diagnosticcriteria criteria(pigmentation). (pigmentation).This Thisdiagnosis diagnosismust mustbebe kept mind any persistent, is is the treatment ofof choice. persistent,enlarging enlargingor orrapidly rapidlygrowing growingnodule noduleon onthe theskin skinand andexcision excisionbiopsy biopsy the treatment choice. Nodular non-pigmented nodule, Nodular melanoma melanoma(NM) (NM)isisusually usuallyaafirm, firm,raised, raised,uniformly uniformlycoloured colouredand andfrequently frequently non-pigmented nodule, that is enlarging and becoming more raised. It accounts for about 15% of melanomas but comprises more that is enlarging and becoming more raised. It accounts for about 15% of melanomas but comprises more than 60% of melanomas >3mm in thickness. than 60% of melanomas >3mm in thickness.
Superficial Spreading Superficial Superficial Spreading Spreading
Lentigo Maligna (LM) Acral Melanoma Subungual Melanoma Melanoma Melanoma (with (with an (with an an “Ugly Duckling” Acral Melanoma Subungual Melanoma with largeMelanoma amelanotic Melanoma “Ugly Duckling” Amelanotic melanoma Nodular with large amelanotic amelanotic amelanotic nodular nodular component) c component (AM) component (AM)
DERMOSCOPY
Skin surface microscopy, dermoscopy, is very useful as an aid in the diagnosis of pigmented skin lesions. Amelanotic melanoma
Dermoscopy represents a form of in vivo microscopy of the epidermis and upper dermis. The technique allows the melanocyte network and melanin pigment to be visualized. General practitioners are encouraged UNUSUAL VARIANTS to learn this technique to facilitate accurate melanoma diagnosis, and those who decide to use it should participate in regular to cause maintain adequate skills. can be reduced number with appropriate Atypical melanoma is training a common of misdiagnosis andBiopsy results rates in a disproportionate of deaths training and experience. from melanoma. Melanoma without pigment, "amelanotic melanoma", can be a problem because of the absence of one of the usual diagnostic criteria (pigmentation). This diagnosis must be kept in mind for any persistent, enlarging or rapidly growing nodule on the skin and excision biopsy is the treatment of choice.
Subungual Melanoma
Melanoma Melanoma (LMM) Some typical melanomas are shown below: Melanoma (SSM)
Acral Melanoma with large amelanotic component (AM)
Melanoma (LMM)
CLINICAL Subungual APPEARANCE Lentigo Maligna Some typical melanomas are shown below:
Acral Melanoma
Early Melanoma “Ugly Duckling” Lentigo Maligna “Ugly Duckling” -- Early Melanoma with large amelanotic Lentigo Maligna Melanoma (LMM) phase) (Flat(AM) component
CLINICAL APPEARANCE
ma
with large amelanotic
component (AM) Some typical melanomas are shown below: component (AM)
LentigoMaligna Maligna Lentigo (LMM) Melanoma Melanoma (LMM)
Lentigo Maligna Melanoma (LMM)
Acral Melanoma Melanoma Subungual APPEARANCE Acral Subungual below: CLINICAL with large amelanotic Melanoma
Nodular melanoma (NM) is usually a firm, raised, uniformly coloured and frequently non-pigmented nodule, that is enlarging and becoming more raised. It accounts for about 15% of melanomas but comprises more than 60% of melanomas in thickness. s in a disproportionate number of>3mm deaths
oma", can be a problem because of the s diagnosis must be kept in mind for any sion biopsy is the treatment of choice.
“Ugly Duckling”
ed and frequently non-pigmented nodule, 15% of melanomas but comprises more
Dermoscope Dermoscope Melanoma Dermoscope Dermoscope Melanoma (utilizes (utilizes cross polarized light) image liquid at skin interface) (utilizes liquid at skin interface) (utilizes cross polarized light)
Nodular Melanoma
Am
Melanoma Dermoscope image
Melanoma: Dermoscopy
UNUSUAL VARIANTS
Atypical melanoma is a common cause of misdiagnosis and results in a dispropor from melanoma. Melanoma without pigment, "amelanotic melanoma", can be a absence of one of the usual diagnostic criteria (pigmentation). This diagnosis mus persistent, enlarging or rapidly growing nodule on the skin and excision biopsy is th
TOTAL BODY PHOTOGRAPHY (TBP) TBP may be used in the follow-up of high risk patients, particularly those with large numbers of melanocytic or dysplastic naevi. Its role in management is still being determined RISK FACTORS The main risk factors for melanoma are: • • • • • •
having a history of previous melanoma the presence of many moles (50+) particularly atypical "dysplastic” naevi a family history of melanoma (one or more) a history of many sunburns sun sensitive skin / fair complexion patient age and sex (increasing age increases the risk of melanoma and males are at greater risk)
Any patient with a history of a previous melanoma has at least a fivefold increased risk of developing a subsequent melanoma compared with the average population. Whilst the early follow up strategy (during the first few years following diagnosis and definitive treatment) will be particularly directed to monitoring for recurrence of that tumour locally, in the regional node fields and at distant sites, the hazard of a further new primary melanoma needs to be recognized and these patients supervised appropriately, especially in the longer term. At the present time, genetic testing has no specific value in the clinical management of patients who are at risk for melanoma. Although some genes associated with melanoma have been detected in familial melanoma patients, the prevalence of these gene changes is, as yet, too low to be clinically useful. Genetic testing is, however, of value to those clinicians and patients interested in clinical research studies – so contributing to finding new facts and a basis for new treatments. Referral of high-risk patients to a dermatologist or melanoma clinic for surveillance is appropriate. PROGNOSIS The thickness of a melanoma is the strongest predictor of outcome. In general, the thinner the lesion the better the prognosis. Other features that have been shown to influence prognosis are: • • • • •
ulceration mitotic rate sex age site
POINTS TO REVIEW •
Achievement of a high level of survival of melanoma patients largely depends on early diagnosis by the primary care clinician.
•
Whilst current detection rates for melanoma with conventional diagnostic features are good they can be improved further by increased awareness of the atypical forms of melanoma, especially the amelanotic and sparsely pigmented variants. Dermoscopy can prove a useful adjunct to diagnosis.
•
Early diagnosis necessitates careful observation by the general practitioner of the body skin surface, examination of suspicious lesions with good illumination, with dermoscopy if possible, and awareness of the clinical appearance and risk factors for melanoma.
•
High risk patients and their partners should be educated to recognise lesions suspicious of melanoma. Regular surveillance is necessary and should be supported by dermoscopy and total body photography as required.
•
High risk patients should be managed in consultation with appropriate specialists.
Based on Clinical Practice Guidelines for the Management of Melanoma in Australia and New Zealand (2008) pre-publication http://www.cancer.org.au/Healthprofession als/clinicalguidelines/skincancer.htm (NHMRC approved 7 November 2008) ACN wishes to thank the many volunteers who have helped in the development and refinement of this aide-memoire. This aide-memoire was developed with funding received from the Australian Government. November 2008
