Chapter 147: Pediatric Melanoma

Patient Story

A 13-year-old red-haired female with a family history of melanoma in her father and multiple moles presents for a routine physical and is found to have a thin 8 mm pink papule on the right neck that has appeared in the last 6 months and occasionally bleeds when it rubs on a shirt (Figure 147-1). A narrow margin excisional biopsy was performed which revealed invasive melanoma 0.7 mm in depth with 2 mitoses per high power field. She was referred to pediatric surgery where she underwent wide local excision and sentinel lymph node biopsy of the neck, which revealed micrometastasis in one node. After PET scan showed no distant metastasis, she underwent lymph node dissection and was enrolled in a clinical trial through a major referral hospital in the region. Her prognosis is guarded, but similar to adults with the same cancer stage.

Epidemiology

• Although extremely rare, malignant melanoma is the most common skin cancer in children and represents 1 percent of all new cases of melanoma.¹

• Between 1973 and 2009, 1230 children in the US were diagnosed with melanoma at a rate of 6 per million overall. Children aged 0 to 9 had the lowest rate at 1.1 per million while children aged 15 to 19 were diagnosed at the highest rate of 18 cases per million.¹

• Melanoma incidence is on the rise in adults and children with the incidence increasing in children by 2 percent per year and 4 to 8 percent per year in adults.¹

• In the US, the death rate is decreasing among persons younger than 65.²

• The lifetime risk of developing melanoma is 1 in 55 for men and 1 in 36 for women.³

Risk Factors

Risk factors can be broadly thought of as genetic risks, environmental risks, and phenotypic risks—arising from a combination of genetic and environmental risks. For example, a fair skinned child (genetic risk) who gets a sunburn (environmental) is much more likely to develop freckles (phenotypic) and melanoma. Childhood sun exposure is a significant risk factor for developing melanoma as an adult.⁴

Environmental Risks

• Exposure to sunlight.

• History of sunburn doubles the risk of melanoma and is worse at a young age.

• Artificial tanning.

• History of immunosuppression.

• Higher socioeconomic status (likely associated with more frequent opportunity for sunburns).

Genetic Risks

• Fair skin, blue or green eyes, red or blonde hair.

• In children, female sex is higher risk, in adulthood, male sex is higher risk.

• Melanoma in a first-degree relative.

• History of ...