The article by Bisseck and colleagueshighlights an importantissue encountered increasinglyby physicians-melanoma in childrenand adolescents. The incidence andmortality of melanoma continues torise. It is now the fifth most commoncancer in men and the seventhmost common cancer in women. Inour practice at the Johns HopkinsMelanoma Center, we have treated agrowing number of children and adolescentswith melanoma, includingmany with stage III disease identifiedby sentinel node technology, similarto that described by Bisseck andcolleagues.
The article by Bisseck and colleagueshighlights an importantissue encountered increasinglyby physicians-melanoma in childrenand adolescents. The incidence andmortality of melanoma continues torise. It is now the fifth most commoncancer in men and the seventhmost common cancer in women. Inour practice at the Johns HopkinsMelanoma Center, we have treated agrowing number of children and adolescentswith melanoma, includingmany with stage III disease identifiedby sentinel node technology, similarto that described by Bisseck andcolleagues.Staging Issues
There are three teaching pointsfrom this article that we would like toemphasize: (1) the role of the sentinelnode in staging melanoma, (2) theclinical characteristics of melanomain children and adolescents, and (3)the pathologic diagnosis of melanomain children and adolescents.The sentinel node technique, pioneeredby Dr. Donald Morton, hasbecome a standard approach in thestaging of melanoma at most centers.The Melanoma Staging Committee ofthe American Joint Commission onCancer has recommended that all patientswho potentially would be enteredinto melanoma clinical trialshave their sentinel lymph nodes stagedas an entry requirement. Otherwise,it is difficult to distinguish betweenthe impact of the natural history ofmelanoma in understaged patients (ie,those who do not have a sentinel nodeexcision) from the treatment effectbeing evaluated in a clinical trial.At Johns Hopkins, patients withclinically negative nodes and whosemelanoma is greater than 1 mm usuallyundergo excision of their sentinelnode for staging purposes. In addition,patients with high-risk T1 melanoma(level IV invasion or ulceratedmelanomas) are also considered forthe sentinel lymph node staging.Whether survival is improved by themore accurate staging and early interventionwith complete lymphectomyin patients with a clinically occult nodalmetastasis must await the results ofthe international multi-institutionalmelanoma surgery trial.Treatment Issues
It is alarming to see the increasingnumber of children and adolescents whopresent with melanoma today. Severaldecades ago, this was a rare event. Majormelanoma centers are now regularlyencountering children andadolescents with invasive melanoma,including some with lymph node metastasis.Many of the children treated atour center do not have the usual riskfactors associated with melanoma, suchas family history, dysplastic nevi,congenital nevi, or multiple moles.No evidence to date demonstrates thatsurvival rates in these younger populationsare different from those inadults, using the standardized tumor,node, metastasis (TNM) prognosticand staging criteria.In our practice at the Johns HopkinsMelanoma Center, we treat children,adolescents, and adults withmelanoma in essentially the same way.This includes offering the sentinelnode staging technique to patients whomeet the criteria described above underStaging Issues. We agree with thetreatment approach described by Bissecket al. Many clinical protocolsexclude melanoma patients who areless than 18 years old so that followupor high-dose interferon-alpha arethe only options after surgery.The Spitz Nevus Factor
The pathologic diagnosis of melanomacan be problematic. As pointedout in this article, the Spitz nevus thatcan arise in children and adolescentshas many of the histologic features ofmelanoma but is not a malignancy. Conversely,amelanotic melanomas aresometimes diagnosed as benign Spitznevi and are undertreated until patientsrelapse with metastatic melanoma. Becauseof the overlapping histopathologicfeatures of invasive melanomaand Spitz nevus in children and adolescents,we highly recommend that anexperienced melanoma pathologist reviewthe pathologic slides of these individualsso that they will be accuratelydiagnosed, staged, and treated.We commend Drs. Bisseck, Shen,and Pranikoff for highlighting theirapproach to this difficult clinical presentationand hope their patient has asuccessful clinical outcome.
The author(s) have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.
Balch CM, Houghton A, Sober A, et al(eds): Cutaneous Melanoma, 4th ed. St. Louis,Quality Medical Press, 2003.
Balch CM, Buzaid AC, Atkins MB, et al:Final Version of the American Joint Commmitteeon Cancer Staging System for CutaneousMelanoma. J Clin Oncol 19:3635-3648, 2001.