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Although the number of nonmelanoma skin cancers is staggering, they have a better than 95% cure rate if detected and treated early. Cutaneous malignant melanoma is a neoplasm arising from the melanocytes that can occur de novo or from a preexisting lesion such as a congenital, acquired, or atypical (dysplastic) nevus. Because overt exposure to ultraviolet light contributes to the formation of skin cancer, dermatologists recommend the following precautions. Wear protective clothing including a wide-brimmed hat, sunglasses, long-sleeved shirt, and long pants. Avoid reflective surfaces such as water, snow, and sand that can reflect up to 85% of the sun's damaging rays. Evidence from epidemiologic studies shows that exposure to solar irradiation is the main cause of cutaneous melanoma in fair-complected persons.3, 4 This causal relation is supported by anatomic differences by sex, migration studies, difference in latitude of residence, and racial differences. Mutations in the gene CDKN2A within the 9p21 region have been demonstrated in familial melanoma kindreds. Each step in tumorigenesis is marked by a new clone of cells with growth advantages over the surrounding tissues.
Clinically, dysplastic nevi appear by age 20 years as two or more disorderly distributed shades of brown and black. Management for patients who have dysplastic nevi, with or without a personal or family history of melanoma, is controversial. In summary, dysplastic nevi should be considered potential precursor lesions to melanoma and deserve careful surveillance and prompt treatment when required. The subtypes of melanoma are distinguished by clinical and pathologic growth patterns: superficial spreading, lentigo maligna, nodular, and acral lentiginous. Lentigo maligna melanoma arises from lentigo maligna, a melanoma in situ (within the epidermis). As with nonmelanoma skin cancers, biopsy is indicated for all suspicious pigmented lesions.
Determining melanoma stage is important for planning appropriate treatment and assessing prognosis. Eighty-five percent of melanoma patients have localized disease (stages I and II) on presentation. The presence of regional lymph node metastases imparts an overall 5-year survival rate of 37% and a 10-year survival of 32%.12 The most important prognostic factor for stage III melanoma is the number of positive lymph nodes. Mohs’ micrographic surgery might prove useful for excision of melanoma, especially lesions located on the head, neck, hands, and feet.
Elective lymph node dissection is defined as removing regional lymph nodes that drain the site of the primary melanoma in the absence of any clinical evidence of nodal metastases. Sentinel lymph node biopsy, a staging and possibly therapeutic procedure, is the most powerful predictor of melanoma recurrence and survival. Systemic chemotherapy is primarily used in patients with advanced stage III (unresectable regional metastases) or stage IV (distant metastases) melanoma.
Therapy directed toward modulating or inducing the immune system against melanoma has gathered considerable interest in recent years. Note: Thickness is defined as the thickness of the lesion using an ocular micrometer to measure the total vertical height of the melanoma from the granular layer to the area of deepest penetration. If grouped according to stage for localized primary melanoma, the overall survival rate is 80%.7 For patients with regional lymph node metastases (stage III disease), survival rates were 27% to 69% at 5 years and 18% to 63% at 10 years.
The goal of regular follow-up evaluation of patients with melanoma is the detection of melanoma recurrence or development of a second primary melanoma.
Primary prevention of melanoma requires reduction of known risk factors in at-risk populations. Greene M, Clark WH Jr, Tucker MA, et al: High risk of malignant melanoma in melanoma-prone families with dysplastic nevi.
Iscoe N, Kersey P, Gapski J, et al: Predictive value of staging patients with clinical stage I malignant melanoma. Reintgen DS, Cox EB, McCarty KS, et al: Efficacy of elective lymph node dissections in patients with intermediate thickness primary melanoma. Veronesi U, Adamus J, Bandiera DC, et al: Inefficacy of intermediate node dissection in stage I melanoma of the limbs. Veronesi U, Adamus J, Bandiera DC, et al: Delayed regional lymph node dissection in stage I melanoma of the lower extremities.
Rosenberg SA, Yang JC, Topalian SL, et al: Treatment of 283 consecutive patients with metastatic melanoma or renal cell cancer using high-dose bolus interleukin-2.
About 80% of these new skin cancer cases will be basal cell carcinoma, 16% will be squamous cell carcinoma, and 4% will be melanoma.
Mortality is higher with melanoma: An estimated 8110 deaths resulted from melanoma in 2007. Noncutaneous primary sites of melanocytes also include the mucosal epithelium, retinas, and leptomeninges. This is crucial because excessive sun exposure in the first 18 years of life increases a person's chances of developing melanoma.
Likewise, melanoma incidence and mortality rates in white persons were inversely correlated with distance from the equator.
The CDKN2A gene is complex and codes for p16 and p14ARF, which both function to suppress cellular growth. 1) are atypical-appearing melanocytic tumors that are histologically characterized by intraepidermal melanocytic dysplasia.
Pathologic confirmation of the clinical diagnosis provides a more solid basis for making further management decisions. Only a small fraction of dysplastic nevi ever progress to melanoma, even in the familial melanoma setting. 2) is presented here because patients often are concerned with the malignant potential of these lesions.

3) begins as a tan irregular macule that extends peripherally, with differing shades throughout. 4) represents approximately 70% of all melanomas and is the most common type of cutaneous melanoma occurring in light-skinned people. 6) accounts for 10% of melanomas overall; however, they are the most common types among Japanese, African Americans, Latin Americans, and Native Americans. 9) is a rare subtype of melanoma that is locally aggressive and has a high rate of local recurrence. Surface epiluminescence microscopy (dermatoscopy) and ultrasound are evolving adjunctive noninvasive diagnostic techniques.4 According to the American Academy of Dermatology (AAD) guidelines, whenever possible the lesion should be excised with narrow margins for diagnostic purposes.
The American Joint Commission on Cancer (AJCC) has revised the four-stage system, reflecting new findings that the Clark level (level of invasion according to depth of penetration of the dermis) offer little prognostic information for tumors thicker than 1 mm, whereas histologic ulceration consistently worsens prognosis across all tumors depths.
About 15% of patients have regional nodal disease, and only about 2% of patients have distant metastases at diagnosis. Patients with nodal micrometastases have an improved survival compared with patients with clinically palpable nodes.
Primary melanomas near a vital structure might require a reduced margin, and aggressive histologic features can suggest a more worrisome tumor and warrant a wider margin.
It has been shown to be an important independent prognostic factor: A positive result predicts high risk of treatment failure. Although most chemotherapy is not that effective, dacarbazine remains the most active drug and is the only FDA-approved chemotherapeutic agent for treating advanced melanoma in the United States.13 The response rate is in the range of 10% to 20%, and patients with metastases in the skin, subcutaneous tissues, or lymph nodes respond most often.
Specific indications include brain metastases, pain associated with bone metastases, and superficial skin and subcutaneous metastases. Unfortunately, when there is evidence of distant metastases (stage IV disease), the 5-year survival rate is only 9% to 19%, and the 10-year survival rate is 6% to 16% (see Table 1). The most important modifiable behavior for melanoma prevention is reduction of ultraviolet exposure. Management of lentigo maligna and lentigo maligna melanoma with staged excision: A 5-year follow-up. Lymphadenectomy in the management of stage I malignant melanoma: A prospective randomized study. Garnis-Jones’ commitment to dermatology has gained her an impressive knowledge of the various problems that affect our skin and the expertise in innovative non-invasive techniques to replenish your skins youth. Garnis-Jones visited the African country Rwanda and the Philippines on humanitarian missions to educate and offer assistance to low funded medical physicians and orphanages in threatened areas. It has been estimated that regular application of sunscreen with a sun protection factor of 15 or greater for the first 18 years of life would reduce the lifetime incidence of nonmelanoma skin cancers by 78%. Because it has been shown that early detection has led to overall increased survival rates for melanoma patients, it is of utmost importance for all physicians to possess the clinical diagnostic skills necessary to identify early melanoma lesions and then refer patients for further appropriate evaluation and treatment. Because melanoma is potentially curable with surgical excision of early, thin lesions, prompt detection, diagnosis, and adequate removal of such lesions are of utmost importance. An intact p16 inhibits cyclin-dependent kinases, a critical class of enzymes, whose function is to promote cellular proliferation by inhibiting the retinoblastoma protein.
Approximately 5% to 10% of patients present with metastatic disease (usually in the lymph node basin) without an identifiable primary lesion.
Dysplastic nevi are important because they are potential histogenic precursors of melanoma and markers of increased melanoma risk.
For people who have one or two suspected dysplastic nevi, excision is reasonable, but periodic examinations should be offered for a lifetime.7 Prophylactic removal of suspected dysplastic nevi is not feasible for people who have numerous dysplastic nevi. It is probable that both environmental and genetic factors play a role in the transition from dysplastic nevus to melanoma. A congenital nevus is defined as a melanocytic nevus that is present at birth or appears within the first few months of life.
It affects adults of all ages, with the peak incidence in the fourth and fifth decades of life. Most subungual melanomas involve the great toe or thumb and generally arise from the nail matrix. When melanoma occurs on the mucosa, it usually develops on the mucosal surfaces of the head and neck (nasal and oral cavities), genital, or anorectal mucosa. It most commonly develops on sun-exposed skin of the head and neck of elderly persons in the sixth or seventh decade of life.
An incisional biopsy technique is appropriate when suspicion for melanoma is low, the lesion is large, or it is impractical to perform a complete excision.
There are now a and b (nonulcerated and ulcerated, respectively) categories for each primary tumor level, for a total of eight.
Patients with melanoma on an extremity and younger age at diagnosis have been shown to have a better prognosis.
Surgical excision at sites such as the fingers, toes, soles, and ears also need separate surgical considerations. It is a relatively low-risk procedure that can help identify high-risk patients who might benefit from additional therapy, such as selective complete lymphadenectomy or adjuvant interferon alfa-2b.
These studies suggest that the role of interferon in the treatment of melanoma is evolving and needs further study. For most patients with stage I or II melanoma, it is recommended that follow-up appointments be scheduled initially every 3 months for 2 years, then every 6 months for 3 years, then once yearly thereafter. She has extensive training in the treatment and presentation of skin cancer and was director of the malignant melanoma research laboratory in Ottawa and Vancouver. Her mission to help all those in need extends beyond her humanitarian work and can be felt in how she approaches cosmetic dermatology.
Although nonmelanoma skin cancers (basal and squamous cell carcinomas) are the most common types of malignancies in humans, melanoma ranks as the sixth most common cancer. Education of the public with regard to the technique of routine self-examination and proper methods of sun protection can greatly improve the chances for early detection and adequate treatment of melanoma (Box 1).

The lower rate of melanoma in darkly pigmented persons results from the protective effect of melanin and smaller number of nevi that can serve as precursor lesions for melanoma.
Less than 2% of patients present with visceral metastases in the absence of an unknown primary lesion.
In patients with many dysplastic nevi, excision for hard-to-monitor areas (scalp, perineum, etc.) should be considered, and serial clinical photography of other lesions should be performed to detect new or changing lesions.
Lentigo maligna occurs equally in men and women, usually in the seventh and eighth decades of life.7 The exact percentage of lentigo maligna that progress to invasive lentigo maligna melanoma is unknown, but it is estimated to be less than 30% to 50%.
Absence of pigmentation within an SSM often represents regression of the melanoma, and the borders are often extremely irregular.
A repeat biopsy should be performed if the initial biopsy specimen is inadequate for accurate histologic diagnosis or staging. A new stage, IIC, has been added, which represents clinically localized melanoma with the worst prognosis (thick, ulcerated primary tumors). Factors associated with an improved prognosis include younger age, female gender, extremity lesions, and histologically negative nodes.
A gamma probe is used to pinpoint the radiolabeled lymph node, which is then removed for histopathologic review.
It provides a psychological benefit for the patient whose sentinel lymph node biopsy does not reveal metastases.2 Because positivity rates for sentinel lymph node biopsy are less than 5% for AJCC T1 melanomas, sentinel lymph node biopsy is considered a low-yield procedure in most thin melanomas.
If the patient has dysplastic nevi, the interval may be continued at every 6 months indefinitely. Understanding the sensitivity of ones skin and looks, all clients are treated with great care and concern.
A multidisciplinary approach, including primary care physicians, dermatologists, surgeons, oncologists, immunologists, radiologists, pathologists, and epidemiologists is necessary to optimize detection and treatment of this increasingly common cancer.
Persons with dysplastic nevi should also be instructed on how to practice skin self-examination every 4 to 6 weeks at home. The risk of developing cutaneous melanoma within small- and medium-sized lesions is low but can be 1% over a lifetime.
The lesion can grow slowly for 5 to 15 years in the precursor form before invasion.7 Although lentigo maligna has a prolonged radial growth phase, when invasion occurs, the result can be lethal. The usual history is that of a slowly changing mole over 1 to 5 years.7 SSM most commonly affects intermittently sun-exposed areas with the greatest nevus density, such as the upper backs of men and women and lower legs of women.
Clinically, nodular melanoma manifests as a uniform blue-black, blue-red, or amelanotic nodule.
Approximately one half of desmoplastic melanomas develop in association with a lentigo maligna. Histologic variables associated with a less-favorable prognosis include increasing tumor thickness, deeper level of invasion, increased mitotic rate, ulceration, diminished lymphoid response, evidence of tumor regression, microscopic satellites, vascular invasion, and non–spindle-cell type tumors. Likewise, melanoma vaccines have been developed to stimulate a specific response against melanoma-associated antigens. Garnis-Jones has also worked in Boston, and was recognized as an international leader in her field by her election to the International Who’s Who.
Combined with her aforementioned experience, the service you receive at Puriste is incomparable to most cosmetic clinics. Almost 40% of children from families with dysplastic nevi melanoma have dysplastic nevi, and all children in whom melanoma eventually develops have dysplastic nevi. Conversely, large congenital nevi have an increased incidence of melanoma of up to 10% over a lifetime. Long-term cumulative rather than intermittent sun exposure is believed to confer the greatest risk for developing lentigo maligna.
Clinically, the lesion is characterized by a tan, brown-to-black, flat macule with color variegation and irregular borders.
Desmoplastic melanoma can manifest clinically as a pigmented macule with or without a nodular component or as a flesh-colored nodule without any surrounding pigmentation. Histologic interpretation should be performed by a pathologist experienced in the microscopic diagnosis of pigmented lesions.4 The differential diagnosis is listed in Box 2. More recently, she was the director of the Niagara psoriasis unit, providing the only narrow-band photo therapy for psoriasis in all of southern Ontario. At least 17% of white adults with melanoma outside the familial melanoma setting have one or more dysplastic nevi, illustrating that dysplastic nevi are markers of risk, as well as potential precursors. Approximately 50% of the melanomas that develop within large congenital nevi do so by age 3 to 5 years, and patients have a melanoma risk of approximately 5% during the first 5 years of life.9 Therefore, smaller congenital nevi can be followed clinically, but early and complete surgical excision of large congenital nevi is usually recommended. Unlike lentigo maligna melanoma, development of acral lentiginous melanoma does not seem to be associated with sun exposure. Because most experts attribute the rising trend in the overall 5-year melanoma survival rate (some 40% in the 1940s to the current rate of 86%) to improved early detection, it is very important for both physicians and the public to be aware of the early warning signs of melanoma and to get appropriate dermatologic evaluation and treatment as soon as possible.
In addition, she was president of the North America Society of Psychotaneous Medicine and the clinical assistant professor at McMaster University in medicine. Garnis-Jones is developing an all natural skin care line, Puriste, and is authoring a healthy skin care and lifestyle book. If complete removal is not possible, the lesion should be closely observed and any nodules or suspicious changes should be biopsied.
It is more common for nodular melanoma to begin in normal skin rather than in a preexisting lesion. Most desmoplastic melanomas are deeply invasive at the time of diagnosis, at least 5 to 6 mm thick.

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