Incidence of melanoma is increasing, with a lifetime risk in the US of 1 in 27 in men and 1 in 40 in women.
Melanoma is the third most common skin cancer, but is the most common cause of skin cancer-related death.
Approximately 17% of patients develop metastatic disease.
Reducing exposure to ultraviolet light is critical for primary prevention of melanoma.
Clinical features of lesion asymmetry, border irregularity, colour variability, diameter >6 mm, and evolution over time should raise suspicion for melanoma and prompt further assessment with dermoscopy.
The prognosis depends on the stage at diagnosis. Over 99% of patients with in-situ melanoma will be cured with simple excision.
Targeted therapies such as immune checkpoint inhibitors and BRAF inhibitors have revolutionised the treatment of metastatic melanoma. Five-year survival rates have improved since the approval of these therapies and are now approaching 30%.
Melanoma is a malignant tumour arising from melanocytes. It is among the most common forms of cancer in young adults and typically presents as a new or changing pigmented (brown or black) skin lesion. The incidence of melanoma peaks in adults more than 70 years of age.
Lesions are often on sun-exposed anatomic locations in people with Fitzpatrick type I (white) skin.
Diagnosis is by physical examination and confirmed by histopathological analysis of a biopsy.
Early stage melanoma has an overall survival rate of nearly 100%, while metastatic melanoma can be rapidly fatal.
Non-cutaneous melanomas may arise from melanocytes in the uvea, meninges, or mucosal membranes. Their management is beyond the scope of this topic.
History and exam
Key diagnostic factors
- altered pigmented lesion (ABCDE signs)
- melanocytic lesion that does not resemble surrounding melanocytic naevi ('ugly duckling')
- spontaneous bleeding or ulceration of a pigmented lesion
- constitutional symptoms
- nail sign: persistent single-nail melanonychia striata
- nail sign: Hutchinson's sign
- atypical dermoscopy findings
- fixed lymphadenopathy
- in-transit metastases
- family history of melanoma
- personal history of melanoma
- personal history of skin cancer (including actinic damage)
- history of atypical naevi
- Fitzpatrick skin type I or II (white skin)
- red or blond hair colour
- high freckle density
- sun exposure
- sun bed use
- light eye colour
- increased numbers of benign-appearing melanocytic naevi
- large congenital naevi
- xeroderma pigmentosum
1st investigations to order
- skin biopsy
Investigations to consider
- sentinel lymph node biopsy
- chest/abdominal/pelvic CT scan
- whole-body PET scan
- brain imaging (CT or MRI)
- BRAF mutational analysis
- NRAS mutational analysis
- serum lactate dehydrogenase (LDH)
- CDKN2A mutational analysis
early stage melanoma (melanoma in situ, stage I, stage II)
resectable advanced melanoma (stage III and stage IV)
unresectable advanced disease (stage III and stage IV)
Prachi Bhave, BE (Hons), MBBS, FRACP
Peter MacCallum Cancer Centre
PB has received honoraria from Novartis and sponsorship from MSD and Novartis.
Yin Wu, MRCP, PhD
Wellcome Trust Clinical Research Career Development Fellow and Honorary Consultant Medical Oncologist
Peter Gorer Department of Immunobiology
King's College London
Department of Medical Oncology
Guy's and St Thomas' NHS Foundation Trust
YW is funded by the Wellcome Trust.
Pablo Fernandez-Peñas, MD, PhD, FACD
Associate Professor of Dermatology
The University of Sydney
PF-P declares that he has no competing interests with the topic Melanoma. PF-P has advisory roles with Amgen, Boehringer Ingelheim, Bristol Meyers Squibb, Leo, Novartis, Lilly, Abbvie, Janssen, Celgene (psoriasis, atopic eczema, hidradenitis), Roche, Merck Sharp & Dohme, Sun Pharmaceuticals, Novartis, and Sanofi. He has been paid to do research for Incyte Europe Sarl, and clinical trials for Arena, Akaal Pharma, Xoma, Kyowa Hakko Kirin, AbbVie, OncoSec, Lilly, CSL Behring, Boehringer Ingelheim, Pfizer, mRage, Eisai, Jiansu Hengrui, Bristol-Myers Squibb, Sun Pharma, Novartis, Roche, Galderma, Regeneron, UCB, GlaxoSmithKline, and Amgen.
Dr Prachi Bhave, Dr Yin Wu, and Dr Pablo Fernandez-Peñas would like to gratefully acknowledge Dr Robyn P.M. Saw, Dr Sophie E. Papa, Dr Alexander M. Menzies, Dr Philip Friedlander, Dr Hobart W. Walling, and Dr Brian L. Swick, previous contributors to this topic.
RPMS is on the advisory board for Novartis, MSD, and Qbiotics and has previously been on the advisory board for Amgen; he has received honoraria from BMS and Novartis. SEP has received honoraria from BMS, MSD, and Novartis to attend conferences; she has participated in advisory boards for BMS, MSD, Amgen, Roche, and GSK. AMM has received honoraria from Novartis and BMS; he is on the advisory boards of MSD and Chugai. PF is a consultant for Genentech. HWW and BLS declare that they have no competing interests.
David Cassarino, MD, PhD
Department of Pathology and Laboratory Medicine
University of California
DC declares that he has no competing interests.
James DeBloom, MD
President of the South Carolina Skin Cancer Center
JB declares that he has no competing interests.
Mai Brooks, MD, FACS
JCCC Women's Cancers Program Area
Jonsson Comprehensive Cancer Center at UCLA
MB declares that she has no competing interests.
Karol Sikora, MA, MBBCh, PhD, FRCR, FRCP, FFPM
KS declares that he has no competing interests.
- Benign/dysplastic melanocytic naevi
- Seborrhoeic keratosis
- Pigmented basal cell carcinoma
- Systemic therapy for melanoma
- Treatment for brain metastases
Skin cancer (melanoma): what is it?
Skin cancer (melanoma): how is it diagnosed and treated?More Patient leaflets
- Log in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer