Melanoma: assessment and management

Why this is important

Atypical Spitzoid lesions continue to be diagnostically challenging. There are no reliably reproducible histological, immunohistochemistry or molecular features that allow exact typing and prognostic assessment of these lesions. The current 'gold standard' is histological examination with expert review, but it is not always possible to distinguish Spitzoid melanoma from benign Spitzoid melanocytic lesions.

Current molecular technologies such as FISH and CGH provide some help, but the results are difficult to interpret and may not be conclusive. Understanding and mapping changes in molecular pathways could predict outcome and inform individual treatment planning.

Why this is important

Mohs micrographic surgery is a microscopically controlled surgical technique designed to allow complete excision of the tumour with minimal tissue loss. The technique can be useful for people with lentigo maligna because their lesions can be very large and located in a cosmetically sensitive site where surgery may cause significant scarring. However, the histological detection of small numbers of melanocytes at the edge of a sample is difficult, and can lead to false negative results. In addition, lentigo maligna may occur in an area of field change with a risk of skip lesions at the edge. Therefore, although Mohs micrographic surgery may ensure complete excision of lentigo maligna, it can be accompanied by the recurrence of a similar lesion in adjacent skin.

Why this is important

It has been reported that suboptimal levels of vitamin D at diagnosis are common in people with melanoma from the north of England and that higher levels are associated with lower melanoma related mortality. However, vitamin D levels are higher in leaner, fitter people and the nature of the relationship between vitamin D levels and melanoma survival is unclear.

There are 2 adjuvant trials of vitamin D supplementation listed as active currently, 1 in Italy and 1 in Australia. However, there are many uncertainties about the design of vitamin D trials, which might become clearer in the next few years. These include the dose of vitamin D, use of concurrent aspirin therapy and the baseline level at which vitamin D supplementation would be started.

Why this is important

Drugs such as immunosuppressants and those used to treat conditions such as diabetes have effects that may affect survival in people with melanoma. For example, metformin, the most frequently prescribed drug for type 2 diabetes, is thought to reduce overall cancer rates in people with diabetes but to increase mortality from melanoma in approximately 40% of these people who have a somatic BRAF mutation.

There is a need to balance the risk of melanoma deaths with the benefits from the most effective treatment of the concurrent conditions. But there is currently no evidence to inform this decision.