Best Dx/Best Rx: Melanoma

From: Subject: Best Dx/Best Rx: Melanoma Date: Wed, 3 Jun 2009 21:51:54 -0700 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0272_01C9E495.822606C0" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.5579 This is a multi-part message in MIME format. ------=_NextPart_000_0272_01C9E495.822606C0 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.acpmedicine.com/acp/newrxdx/rxdx/dxrx0210.htm Best Dx/Best Rx: Melanoma

Melanoma

Allan C. Halpern, M.D.
Patricia L. Myskowski, = M.D.=20
Joan and Sanford I. Weill Medical College of Cornell University = and=20 Memorial Sloan-Kettering Cancer Center

Defin= ition/Key=20 Clinical Features
Diffe= rential=20 Diagnosis
Best = Tests
Best = Therapy
Best = References

Definition/Key Clinical=20 Features

Malignancy arising from a melanocyte; vast = majority=20 occur in skin=20
Possible melanoma with any pigmented skin = lesion meeting=20 following criteria:
- Recent change=20
- Asymmetry=20
- Border irregularity=20
- Color variation=20
- Diameter > 6 mm=20
- Changes color, shape, size relative to = patient's other=20 moles
Moles (nevi) are strongest phenotypic melanoma = risk=20 markers, especially increased numbers of moles and atypical moles = (dysplastic=20 nevi) (i.e., those that are large [> 5 mm] with variegate = pigmentation,=20 ill-defined borders)

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Differential = Diagnosis

Dysplastic nevus=20
Lentigines=20
Sunburn freckles=20
Traumatized nevus=20
Thrombosed angioma=20
Pigmented basal cell carcinoma=20
Pigmented Bowen disease=20
Dermatofibroma
Atypical seborrheic keratosis
Amelanotic melanoma
Spitz nevus

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Best=20 Tests

Simple visual inspection, including scalp, = genitalia,=20 soles of feet
Risk factors=20
- Patient history of changed lesion=20
- Nevi (large number, atypical)=20
- Fair complexion=20
- Tendency to burn=20
- Inability to tan=20
- Freckling=20
- Family history of melanoma
Screening family members for melanoma = (particularly=20 multiple melanoma) may be useful=20
Diagnostic aids=20
- Dermoscopy=20
- Baseline photographs of entire body =
Definitive diagnosis: biopsy by full-thickness = excision=20 preferred

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Best=20 Therapy

Primary Site

Primary cutaneous melanoma managed surgically = with=20 definitive reexcision=20
- 1-cm margins for melanomas < 1 mm = thick=20
- 2-cm margins for melanomas 1=964 mm = thick=20
- 2- to 4-cm margin for melanomas > 4 mm = thick=20
- Primary closure and reconstructive flaps = preferable to=20 skin grafts

Lymph Nodes

Therapeutic lymph node dissection for = clinically evident=20 regional lymph node disease=20
Sentinel lymph node biopsy increasingly used = for=20 melanoma > 1 mm thick; sentinel node status strongly correlated = with 5-yr=20 survival

Adjuvant Therapy

For patients with cutaneous or regional = disease who are=20 surgically rendered free of disease but at high risk for recurrence or = metastasis=20
High-dose regimen of interferon alfa approved = by=20 FDA=20
Clinical trials of adjuvant vaccines to be=20 considered

In-Transit Metastases

Slow-growing individual occurrences managed=20 surgically=20
Limb perfusion therapy for extensive = occurrences=20 confined to extremity

Distant Metastases

Monotherapy with dacarbazine is the standard = treatment=20 against which all others are judged=20
Interleukin-2 is FDA-approved=20
Clinical trials of multidrug treatment and = immunologic=20 therapies to be considered

Chemotherapeutic agents

Dacarbazine: for distant metastatic disease; = objective=20 responses in approximately 5%=9620%; durable complete responses = rare=20
Interferon alfa: in adjuvant setting; two = studies showed=20 small but statistically significant improvement in overall = survival=20
- Dose: 20 million U/m² I.V. daily = for 1 mo=20 followed by 10 million U/m² S.C. three times/wk x 48 = wk=20
Interleukin-2: low response rate but some = responses=20 durable=20
- Dose: 600,000=96720,000 U/kg S.C. t.i.d. on = days 1=965,=20 15=9619

Best Quality

Screening for additional primary melanomas on=20 follow-up=20
- In dysplastic nevi, melanoma detection = predicated on=20 specialized visual exam aided by self-exam and professional = follow-up to=20 identify changing lesion=20
- Photographically assisted follow-up in = high-risk=20 individuals

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Best References

Tsao H, et al: N Engl J Med 351:998, 2004 [PMID=20 15342808]

April=20 2009

=A9 2009 BC Decker Inc. 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