Symptoms and signs of primary melanoma: important indicators of Breslow depth

Operative management of patients with cutaneous melanoma is guided primarily by the pathologic determination of Breslow depth. Differentiating early from more advanced melanoma is not always straightforward and may be complicated by pathologic misdiagnosis, inappropriate biopsy techniques, or poor specimen handling. Inconsistencies between the patient's history and the pathologist's interpretation may alert the physician to the possibility of misdiagnosis. In this setting, awareness of the signs and symptoms (S/S) of thin versus intermediate or deep melanoma may be helpful in guiding management. The authors performed a prospective evaluation of the S/S reported by patients who presented at Memorial Sloan-Kettering Cancer Center with invasive primary melanoma.

The authors prospectively evaluated 369 patients with a detailed questionnaire regarding their S/S at the time of their initial visit. Multivariate logistic regression was employed to study the association between S/S reported by the patient and Breslow depth of the primary lesion, adjusting for gender, age, and anatomic site. Patients were grouped by the Breslow depth of their primary tumors into three categories for analysis: those with thin (< or = 1.0 mm), intermediate (1.0-4.0 mm), and thick (> or = 4.0 mm) lesions.

Gender, age, and primary site were not significantly predictive of increasing category of Breslow depth. Most patients reported at least one S/S (n=278 [75%]). The most common S/S reported was an increase in size (n=187 [51%]), followed by a change in color (n=147 [40%]). Bleeding (n=95 [26%]), lump (n=86 [23%]), itching (n=83 [22%]), skin breakdown (n=66 [18%]), and pain (n=24 [7%]) were less common. In a multivariate analysis, the S/S most strongly associated with an increased category of Breslow depth was bleeding (odds ratio [OR] 7.5), followed by pain (OR 3.3), lump (OR 2.2), itching (OR 1.9), and change in size (OR 1.7). The only S/Ss not independently associated with an increasing category of Breslow depth were a change in color and skin breakdown. The presence of one or more S/S was associated significantly with an increased category of Breslow depth of the primary melanoma (1 or 2 S/S vs. no S/S: OR, 4; > or= 3 S/S vs. no S/S: OR, 24).

Most S/Ss of cutaneous melanoma are associated with an increasing risk of a deep primary lesion. Understanding this relationship can be valuable in patient management, especially when pathologic data are incomplete or inconsistent with the patient's history.