Pediatric Melanoma: Beyond the ABCDs

Guest blog post by Vernon K. Sondak, MD, Chair, Department of Cutaneous Oncology and Jane L. Messina, MD, Senior Member, Departments of Anatomic Pathology and Cutaneous Oncology at H. Lee Moffitt Cancer Center. Dr. Sondak and Dr. Messina serve on the MRF Pediatric Melanoma Scientific Steering Committee.

Tremendous progress has been made in the early diagnosis and effective treatment of adult patients with melanoma. In fact, in just the past three years, according to American Cancer Society statistics the death rate from melanoma in the USA has dropped over 28%! The biggest factors in this improvement are earlier detection and improved treatments to prevent and treat advanced melanoma. These new treatments for adults haven’t been extensively studied in children, and we’ll have more to say about how they might be used in pediatric melanoma in a future blog. Early detection and diagnosis, which has proven so important in adults, hasn’t yet been so successful in children. Here are some tips to think about in promoting the early detection and accurate diagnosis of melanoma in children.

1. Most pediatric melanomas don’t follow the standard ABCD rules, but some do. In adults, Asymmetry, Border irregularity, Color changes and a Diameter >6 mm (the size of the eraser on the tip of a pencil) aid in the early detection of most melanomas. Only a minority of melanomas in young children follow these rules – but we don’t want to miss those cases either. For the rest of the cases, studies have shown that they are frequently Amelanotic (not darkly pigmented), Bumps that may be Bleeding, uniform Color and Developing from normal skin rather than a preexisting mole. So there may actually be two different sets of ABCD rules, one that is more appropriate for “adult-type” melanoma, and the other that is more appropriate for children.
2. Normal (noncancerous) moles start to appear in childhood and continue to develop through the teen years into adulthood. So just because your son or daughter has a new spot on their skin, it does not mean they have melanoma. You can minimize the number of moles your child will get by protecting them from excessive sun exposure and especially sunburns, but nothing can prevent all moles from occurring. If “funny looking (dysplastic) moles” run in your family – although we don’t know all the genes involved in controlling mole inheritance – there’s a good chance one or more of your children will have similar moles. If this occurs, regularly scheduled skin exam are essential, since these moles can indicate an individual at higher risk of melanoma.
3. You know your child’s skin better than anyone. Regardless of the “rules,” if something seems wrong on your child’s skin, get it checked out. And if a skin lesion continues to grow, consider having it biopsied or removed – even if that means getting a second opinion to do so. Be on the lookout for the “ugly duckling,” a mole or other skin lesion that stands out as clearly different in size, shape, color or the rapidity of its growth compared to all the others. If you see an ugly duckling mole on your child’s skin, get it checked out.

Only a biopsy can definitely tell if a skin lesion is melanoma or something else. But in the case of many children, after the biopsy, the challenges may be just starting.

1. Melanoma in children is fortunately rare, but recognizing it under the microscope can be as tricky as spotting it on the skin. Even an experienced dermatopathologist with expertise in pediatric skin biopsies can have a tough time, but they are much more likely to come up with the correct diagnosis than a less experienced general pathologist. If your child’s biopsy result is not definitive, don’t hesitate to ask for a second opinion from a pathologist specializing in pediatric melanoma cases.
2. In children, skin biopsies are often small and incomplete. Sometimes, more information is available when the entire skin lesion is removed, so complete removal is often required in cases of diagnostic uncertainty.
3. Under some circumstances, testing the lymph nodes by sentinel lymph node biopsy – a procedure routinely used for adult melanoma and some other skin cancers – can be helpful in diagnosing melanoma in children and determining if it has already spread to the lymph nodes.
4. Other specialized tests, such as FISH and CGH, can be used to supplement the information that the pathologist gets under the microscope – but usually are not absolute in determining whether something is melanoma or not. These tests may or may not be covered by insurance, so be sure you understand what testing is being ordered and how it might be used.
5. Even after complete removal and extensive testing, some cases cannot be definitely classified as either totally benign or definitely melanoma. We have developed a 5-point grading scale for these cases, where 1 is definitely benign and 5 is definitely melanoma. This can help with communicating about the risk that the lesion is actually a melanoma, with a capacity to spread. Our philosophy is to consider “the worst-case scenario” and treat accordingly, recognizing that most pediatric melanoma cases are in fact treatable and curable, so the worst-case scenario is not always so bad – and almost always better than missing a diagnosis of melanoma when present.

To summarize, no one rule or principle will allow us to detect and diagnose all cases of childhood melanoma. Like they say in the airport, “if you see something, say something.” Check out www.melanoma.org for more tips and suggestions, and other valuable resources.

By increasing awareness and funding the most promising research, the MRF is committed to improving the early detection, diagnosis and treatment of pediatric melanoma. Please consider a tax-deductible gift to support this life-saving work today.

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