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The ABCDEs of Detecting Pediatric Melanoma Falls Short

Dermatology Today recently reported on a study that reviewed conventional criteria for detecting skin cancer in children since individuals 19 years and younger commonly present atypical melanoma symptoms. The current method includes, “ABCD”: asymmetry, border irregularity, color variation and diameter greater than 6 mm.

The Study
Dr. Kelly M. Cordoro, associate professor of dermatology and pediatrics at the University of California, San Francisco, and her team examined 70 patients who were 19 years old and younger. Sixty of the patients were diagnosed with melanoma, and the remaining 10 were diagnosed with melanocytic tumors that had been treated as melanoma. The research team divided the patients into two groups according to their age at diagnosis: one group included patients aged 0-10 (totaling to 19 individuals), and the other group included patients 11-19 (totaling to 51 individuals).

The Results
The conventional ABCD criteria were largely inadequate for detecting melanoma in children, especially the younger group: the team found that lesions in 60% of children in the younger group and 40% of children in the older group did not present with conventional ABCDE criteria. According to the study, the lesions were characterized by amelanosis, bleeding bumps, uniform color, variable diameter and de novo development.

Furthermore, even though more than 90 percent of the younger patients had stage 2a disease or higher, 44% of the lesions were not classifiable by experienced dermatopathologists into conventional adult subtypes. Cordoro states that these diagnostic delays are most likely due to the complexity of these lesions.

Still, the evolution of the skin lesion, the “E”, “proved to be the more sensitive indicator,” according to Dr. Cordoro. She states, “The criterion of evolution was universally valuable, capturing nearly 100 percent of the entire cohort of pediatric melanomas. We must remain mindful of this as we interview and examine our patients. Though growth is a form of evolution, nevi in children are often changing with age and [dermatology providers] are very good at recognizing these banal transitions. More important are new, persistent pink or red papules or nodules or pigmented nevi that have developed new symptoms such as itching, crusting or bleeding. The latter are warning signs, and warrant biopsy.”

Because national cancer databases and registries lack detailed information about the recent history and presenting features of melanoma, Dr. Cordoro notes that the group of younger children is one of the largest groups reporting detailed clinical and histopathological features of melanoma. She states, “This is critically important information for clinicians because we need to know what we should be looking for in order to not miss this diagnosis in children. In fact, 86 percent of children less than 10 years old in this study had a greater than six-month delay in diagnosis, most likely due to a low index of suspicion and atypical clinical presentations common to this age group.”

Because many children will still present typical melanomas, the study’s authors conclude that additional ABCD detection criteria (Amelanotic; Bleeding, Bump; Color uniformity; De novo, any Diameter) used together with conventional ABCDE criteria may facilitate earlier recognition and treatment of melanoma in children, and Dr. Cordoro notes that the criteria is meant to raise awareness and serve as a reminder of the alternate presentations of these lesions in children.

Sources: 1, 2

Image: Daniel Go

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