PEDIATRICS Vol. 115 No. 3 March 2005, pp. 802-803 (doi:10.1542/peds.2004-2770)
COMMENTARY |
Melanoma in Children: Heightened Awareness of an Uncommon but Often Curable Malignancy
Department of Surgery
Johns Hopkins Medical Institutions
Baltimore, MD 21287
Melanoma is thought to occur rarely in children. However, a number of recent publications and our own experience clearly indicate that a profound change in the natural history of melanoma is now occurring and that melanoma, indeed, is occurring much more frequently in children and teenagers. In this issue of Pediatrics, Ferrari et al report the experience of the Instituto Nazionale Tumori (Milan, Italy) with childhood melanoma over a 25-year time span.1 The clinical presentation, treatment, and outcome for children 
14 years old are described in this retrospective study. The authors report that among 33 patients, half had what could be considered an atypical presentation, with amelanotic or other unusual lesion, and that children <10 years old as a group had better outcomes than children from 10 to 14 years old.
There is increasing evidence that the incidence of melanoma is rising in children.2,3 In our own practice at the Johns Hopkins Melanoma Center, we have observed a noticeable increase in melanoma cases among the pediatric population over the past few years, particularly in adolescents. The importance of considering the diagnosis in children is clear: when detected and treated early, most patients will do well. It is imperative that pediatricians, pediatric dermatologists, pediatric surgeons, and other specialists have an increased alertness to the criteria for diagnosis and clinical management of this malignancy.
We have been impressed that the clinical presentation of childhood melanoma can sometimes be atypical. In the Italian series, approximately half of the cases were clinically amelanotic. Most lesions were raised, and most had well-defined borders. None of the patients were known to have a family history of melanoma. It is unfortunate that delay in diagnosis is common; in the pediatric population, delay can sometimes be ascribed to atypical presentation but at other times to a reluctance to consider the diagnosis, even when faced with a skin lesion that would be considered suspicious for melanoma in an adult. To afford the best opportunity for a good outcome, it is important that health care providers for children be aware of the possibility of melanoma in children and alert for any skin lesions that are new or unusual in appearance. It is often the parent who insists on a biopsy, complaining of a skin lesion that looks unlike any other on the child.
Treatment decisions for children are guided by clinical studies done in adults, and the standard treatment today is surgery. All the children in this study who had a recognized primary lesion were treated with wide excision of the lesion, and all with known nodal metastases were managed with lymphadenectomy. Three received adjuvant chemotherapy, and 2 received adjuvant radiotherapy. It is easy to rationalize the need for and use of "adult" surgical management for children with melanoma. The use of lymphatic mapping and sentinel node biopsy as a staging tool has been reported in children and seems to be at least as useful in children as in adults. Systemic adjuvant treatments are more problematic. 
-Interferon is Food and Drug Administration–approved for high-risk, resected melanoma and remains the only adjuvant treatment available for children. Clinical trials of systemic therapies have not been open to children, and thus families of children with high-risk, resected melanoma must choose between -interferon and observation. Patterns of recurrence in the current study were similar to those in adults, with lymph nodes and soft tissues being common sites of metastatic disease. In this small series, children <10 years old seemed to have better survival than the older children even though the median thickness of the primary lesions in the younger children was greater.
We do not know if the biology and natural history of melanoma in children differs in some fundamental way from that of melanoma in adults. New investigations into the molecular biology of melanoma may shed light on the disease in both adults and children, and someday we may be able to characterize ways in which the disease differs at a molecular level across age groups. Prospective clinical trials for children with melanoma have not been done, and we are left to use "adult" criteria for clinical management. It is clear that surgery is effective as the primary treatment for children based simply on the numerous case series reporting long-term survival in some patients. We believe that children with T1b, T2, T3, and T4 melanoma with no clinically evident regional or distant disease should undergo surgical staging with lymphatic mapping and sentinel lymph node excision. The use of -interferon as an adjuvant treatment has been reported in children, but its effectiveness, as in adults, remains controversial.4
It remains unclear if survival outcomes are inherently different for children than for adults. However, it is clear that melanoma can and does occur in children and adolescents, apparently with increasing frequency. Most children with melanoma have no family history of the disease, and they may lack other risk factors such as congenital nevi and atypical nevi. The disease presentation may also differ from the typical presentation in adults, with an amelanotic skin lesion more suggestive of verruca or pyogenic granuloma. It is clear also that melanoma in children, as in adults, has the potential for excellent outcome, particularly when diagnosed early. Therefore, it is important to recognize the possibility of this uncommon disease in children and to biopsy skin lesions that appear suspicious or about which the patient or parent has concern. More study is needed of this special population, and we encourage more epidemiologic, biological, and clinical studies focusing on children and teenagers with melanoma.
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FOOTNOTES |
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Address correspondence to Julie R. Lange, MD, ScM, Department of Surgery, Johns Hopkins University, 600 N Wolfe St, Carnegie 681, Baltimore, MD 21212. E-mail: jlange{at}jhmi.edu
No conflict of interest declared.
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REFERENCES |
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 TOP REFERENCES |
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- Ferrari A, Bono A, Baldi M, et al. Does melanoma behave differently in younger children than in adults? A retrospective study on 33 cases of childhood melanoma from a single institution.
Pediatrics. 2005;115
:649
–654
[Abstract/Free Full Text] - Hamre MR, Chuba P, Bakhshi S, Thomas R, Severson RK. Cutaneous melanoma in childhood and adolescence. Pediatr Hematol Oncol. 2002;19 :309 –317[CrossRef][Web of Science][Medline]
- Karlsson P, Boeryd B, Sander B, Westermark P, Rosdahl I. Increasing incidence of cutaneous malignant melanoma in children and adolescents 12–19 years of age in Sweden 1973–1992. Acta Derm Venereol. 1998;78 :289 –292[CrossRef][Web of Science][Medline]
- Chao MM, Schwartz JL, Wechsler DS, Thornburg CD, Griffith KA, Williams JA. High-risk surgically resected pediatric melanoma and adjuvant interferon therapy. Pediatr Blood Cancer. 2004; In press
PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics
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