Charles M. Balch, M.D., used to see a pediatric melanoma case every one to two years. In recent years, the professor of surgery and oncology at Johns Hopkins Medical Institution, Baltimore, Md., says he sees a child or teenager with melanoma every one to two months.
The youngest that Dr. Balch has yet to treat was an 8-year-old girl with stage IIIA melanoma. She had a mole on her thigh, intermediate thickness. Dr. Balch did a wide excision and sentinel node only to find the youngster had a positive inguinal lymph node.
"She had to have an inguinal lymph node dissection," he says. "That was three years ago and she has done well since then in careful follow-up."
The bottom line, according to Dr. Balch: Pediatric melanoma, which he defines as melanoma among children and teens, remains uncommon but is growing in prevalence.
If, in fact, there are more children today with melanoma, the cause for the increase is unknown, Dr. Balch says.
"What is striking to me in interviewing these patients and their families is that they do not have the typical, so-called high-risk criteria that we would attribute to adult cancers," Dr. Balch says. "It is uncommon, if ever, that they have a family history of melanoma; that they have a history of severe sunburning; or that they have dysplastic nevi or congenital nevi."
Collectively, according to the oncologist, these are not children presenting with benign Spitz nevi; rather, these are true melanomas.
Robert Johr, M.D., a clinical professor of dermatology, associate clinical professor of pediatrics and director of the pigmented lesion clinic at the University of Miami, Miami, says he has not seen an increase in pediatric melanoma.
In practice for 26 years in Florida, Dr. Johr says that the incidence of melanoma is still very low among pediatric patients (which he describes as 20 years and younger). But he agrees that dermatologists and pediatricians should do a better job at maintaining a level of suspicion.
"I think you have to be on the lookout for melanoma and dysplastic moles in children; you have to do complete skin examinations," Dr. Johr says.
A level of suspicion The same rules apply for biopsying children as do for adults, according to Dr. Balch.
"These are always moles that change. They may not have the typical appearance of a melanoma, in terms of being shades of brown or black, but they are definitely moles that change," he says.
Such lesions should be examined by an experienced dermatopathologist, experienced in melanoma, to distinguish between an invasive melanoma and Spitz nevus, Dr. Balch says.
Dermatologists and oncologists would treat these children and teenagers basically with the same criteria that they use in adults with melanoma, which is to perform a wide excision, according to the thickness, and to perform a sentinel lymph node in those who have stage IB or II melanoma and who are clinically node negative, according to Dr. Balch.
Dr. Johr adds a step before excising a young patient. Dr. Johr highly recommends dermoscopy before excision, though it is not the standard of care in the United States.