History

Fact Explanation
Recent changes of preexisting naevi Melanoma is a malignant epidermal tumor which arises from melanocytes. History of rapidly increasing diameter, variation of color, symmetry are important symptoms to suspect melanoma. Itching, bleeding and ulceration are other possible changes that can occur with malignant transformation. Melanoma has superficial and radial growth phase. The malignant cells are at first confined to the epidermis and uppermost dermis, but eventually invade more deeply and may metastasize. [1],[2],[3],[4],[5],[6],
Onset of satellite lesions near preexisting naevi Due to superficial spread satellite lesions can appear near the preexisting naevi. [1],[2],[3],[4],[5],[6],
New onset of pigmented nodule Melanoma can also arise denovo. There for new onset of pigmented nodule is a important symptom. Usually occurs most of the skin. But also can occur in oral cavity, nasal mucosa, choroid layer in eye, vagina etc. [1],[2],[3],[4],[5],[6],[7]
History of having very large or numerous naevi The risk of developing a malignant melanoma is highest in those with atypical naevi, congenital melanocytic naevi or many banal melanocytic naevi. [1],[2],[3],[4],[5],[6],
History of sun exposure The incidence and mortality increase with decrease latitude. For melanomas , the number of sunburns seems more relevant than cumulative ultraviolet radiation dose. Therefore who are expose to sun for short intensive period are more vulnerable. [1],[2],[3],[4],[5],[6],[8],[9]
Fair skinned Episodic exposure of fair skinned ( skin type 1& 11) individuals to intense sun light is a identified risk factor. Specially fair skin which is not get tan with sun exposure has a higher risk. [1],[2],[3],[4],[5],[6],[8],[9]
Past history of melanoma Patients who had melanoma has a higher risk of developing second melanoma. [1],[2],[3],[4],[5],[6],
Immunodefficiency History of immuno defficiency such as organ transplant, immuno suppressive drug therapy is a important risk factor for melanoma. [1],[2],[3],[4],[5],[6],
Family history of melanoma or skin cancer 10% of patients with melanoma have a positive family history of melanoma. [1],[2],[3],[4],[5],[6],
Family history of moles Family history of irregular atypical moles or numerous moles is important due to multiple nevus syndrome [1],[2],[3],[4],[5],[6]
Family history of pancreatic cancer and astrocytoma : Familial melanoma syndrome is associated with pancreatic cancer and astrocytoma .[1],[2],[3],[4],[5],[6]
References
  1. MAVROGENIS A, BIANCHI G, STAVROPOULOS N, PAPAGELOPOULOS P, RUGGIERI P. Clinicopathological features, diagnosis and treatment of clear cell sarcoma/melanoma of soft parts. Hippokratia [online] 2013 Oct, 17(4):298-302 [viewed 25 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25031505
  2. OLIVEIRA A, ARZBERGER E, MASSONE C, ZALAUDEK I, FINK-PUCHES R, HOFMANN-WELLENHOF R. Melanoma and satellite blue papule. Dermatol Pract Concept [online] 2014 Jul, 4(3):63-6 [viewed 25 September 2014] Available from: doi:10.5826/dpc.0403a12
  3. ALONSO SR, ORTIZ P, POLLáN M, PéREZ-GóMEZ B, SáNCHEZ L, ACUñA MJ, PAJARES R, MARTíNEZ-TELLO FJ, HORTELANO CM, PIRIS MA, RODRíGUEZ-PERALTO JL. Progression in Cutaneous Malignant Melanoma Is Associated with Distinct Expression Profiles : A Tissue Microarray-Based Study Am J Pathol [online] 2004 Jan, 164(1):193-203 [viewed 25 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1602212
  4. WESTERDAHL J, INGVAR C, MåSBäCK A, JONSSON N, OLSSON H. Risk of cutaneous malignant melanoma in relation to use of sunbeds: further evidence for UV-A carcinogenicity Br J Cancer [online] 2000 May, 82(9):1593-1599 [viewed 25 September 2014] Available from: doi:10.1054/bjoc.1999.1181
  5. MOREIRA J, MOREIRA E, AZEVEDO F, MOTA A. [Cutaneous malignant melanoma: a retrospective study of seven years (2006-2012)]. Acta Med Port [online] 2014 Jul-Aug, 27(4):480-8 [viewed 25 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25203957
  6. CHEN L, XIONG Y, WANG H, LIANG L, SHANG H, YAN X. Malignant melanoma of the vagina: A case report and review of the literature. Oncol Lett [online] 2014 Oct, 8(4):1585-1588 [viewed 25 September 2014] Available from: doi:10.3892/ol.2014.2357
  7. KHARMOUM S, MOHAMED M, BENHAMMANE H, KHARMOUM J, TOURI S, SETTI K, BENSOUDA Y, BOUTAYEB S, ELGHISSASSI I, MRABTI H, EL KHANNOUSSI B, SBITTI Y, ERRIHANI H. Conjonctival melanoma metastatic to the breast: a case report. BMC Res Notes [online] 2014 Sep 9, 7(1):621 [viewed 25 September 2014] Available from: doi:10.1186/1756-0500-7-621
  8. JANG HS, KIM JH, PARK KH, LEE JS, BAE JM, OH BH, RHA SY, ROH MR, CHUNG KY. Comparison of Melanoma Subtypes among Korean Patients by Morphologic Features and Ultraviolet Exposure. Ann Dermatol [online] 2014 Aug, 26(4):485-90 [viewed 25 September 2014] Available from: doi:10.5021/ad.2014.26.4.485
  9. VALACHOVIC E, ZURBENKO I. Skin cancer, irradiation, and sunspots: the solar cycle effect. Biomed Res Int [online] 2014:538574 [viewed 25 September 2014] Available from: doi:10.1155/2014/538574

Examination

Fact Explanation
Irregularly pigmented asymmetrical macule or plaque. Their margins are irregular with reniform projections and notches. Their may be bleeding and ulceration over the surface. The total body skin examination in a well lit room is very important to identify skin lesions. Must assess the number, size, color, border and surface carefully. Their are four main types of malignant melanoma. [1],[2],[3],[4],[5],[6],[7],
Irregularly pigmented, irregularly shaped macule on exposed skin. Lentigo malignant melanoma commonly affects the elderly population. The macule may have been enlarging slowly for many years. [1],[2],[3],[4],[5],[6],[7],
A nodule coming up within varied colored plaque. Superficial spreading melanoma is the most common type in Caucasoid. [1],[2],[3],[4],[5],[6],[7],
Irregularly pigmented macule or plaque on palms or soles. Acral lentigious melanoma is the most common type in Chinese and Japanese people. This is rare among Caucasoid. [1],[2],[3],[4],[5],[6],[7],
Pigmented nodule without preceding insitu stage. Nodular melanoma is the most rapidly growing and aggressive type. [1],[2],[3],[4],[5],[6],[7],
lymph node enlargement The regional lymph node groups must assess to identify their Involvement. [1],[2],[3],[4],[5],[6],[7],
References
  1. CHIARAVALLOTI AJ, LADUCA JR. Melanoma screening by means of complete skin exams for all patients in a dermatology practice reduces the thickness of primary melanomas at diagnosis. J Clin Aesthet Dermatol [online] 2014 Aug, 7(8):18-22 [viewed 25 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25161756
  2. JANG HS, KIM JH, PARK KH, LEE JS, BAE JM, OH BH, RHA SY, ROH MR, CHUNG KY. Comparison of Melanoma Subtypes among Korean Patients by Morphologic Features and Ultraviolet Exposure. Ann Dermatol [online] 2014 Aug, 26(4):485-90 [viewed 25 September 2014] Available from: doi:10.5021/ad.2014.26.4.485
  3. OLIVEIRA A, ARZBERGER E, MASSONE C, ZALAUDEK I, FINK-PUCHES R, HOFMANN-WELLENHOF R. Melanoma and satellite blue papule. Dermatol Pract Concept [online] 2014 Jul, 4(3):63-6 [viewed 25 September 2014] Available from: doi:10.5826/dpc.0403a12
  4. ALONSO SR, ORTIZ P, POLLáN M, PéREZ-GóMEZ B, SáNCHEZ L, ACUñA MJ, PAJARES R, MARTíNEZ-TELLO FJ, HORTELANO CM, PIRIS MA, RODRíGUEZ-PERALTO JL. Progression in Cutaneous Malignant Melanoma Is Associated with Distinct Expression Profiles : A Tissue Microarray-Based Study Am J Pathol [online] 2004 Jan, 164(1):193-203 [viewed 25 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1602212
  5. CHEN L, XIONG Y, WANG H, LIANG L, SHANG H, YAN X. Malignant melanoma of the vagina: A case report and review of the literature. Oncol Lett [online] 2014 Oct, 8(4):1585-1588 [viewed 25 September 2014] Available from: doi:10.3892/ol.2014.2357
  6. KHARMOUM S, MOHAMED M, BENHAMMANE H, KHARMOUM J, TOURI S, SETTI K, BENSOUDA Y, BOUTAYEB S, ELGHISSASSI I, MRABTI H, EL KHANNOUSSI B, SBITTI Y, ERRIHANI H. Conjonctival melanoma metastatic to the breast: a case report. BMC Res Notes [online] 2014 Sep 9, 7(1):621 [viewed 25 September 2014] Available from: doi:10.1186/1756-0500-7-621
  7. MOREIRA J, MOREIRA E, AZEVEDO F, MOTA A. [Cutaneous malignant melanoma: a retrospective study of seven years (2006-2012)]. Acta Med Port [online] 2014 Jul-Aug, 27(4):480-8 [viewed 25 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25203957

Differential Diagnoses

Fact Explanation
Melanocytic naevi Melanocytic naevi (moles) are localized benign tumors of melanocytes. With exception of congenital melanocytic naevi, most appear in early childhood, often with a sharp increase in numbers during adolescence and after severe sun burns. [1],[2]
Seborrhoeic keratosis Seborrhoeic keratosis usually arises after the age of 50 years, but flat inconspicuous lesions are often visible earlier. They are often multiple but may be single. The lesions are most common on face and trunk. they have a stuck - on appearance [1],[2]
Pigmented basal cell carcinoma Pigment may be present in all types of basal carcinoma, causing all or part of the tumor to be brown or have specks of brown or black within it. [1],[2]
Sclerosing haemangioma Haemangioma is a benign proliferation of blood vessels. Dermoscopy is most helpful in distinguishing from neavus or melanoma. [1],[2]
Lentigenes They are may be found any part of the skin and mucous membranes. They are usually grey brown rather than black, and develop more often after adolescence. [1],[2]
Subungal or periungal hematoma Usually their is a positive history of trauma. The larger subungal haematoma s are usually easy to identify.[1],[2]
Pyogenic granuloma An amelanotic melanoma is most often confused with pyogenic granuloma. Pyogenic granuloma usually present as a smooth or lobulated, red to purple, painless lump. [1],[2]
Squamous cell carcinoma An amelanotic melanoma is rarely confused with squamous cell carcinoma. Squamous cell carcinoma occur on head and neck commonly involving lower lip, external ear , forehead and scalp. [1],[2]
Talon noir Talon noir is a pigmented petichial area on heel following minor trauma from ill-fitting training shoes. Usually it is less pigmented compared to melanoma.[1],[2]
References
  1. LALLAS A, APALLA Z, ARGENZIANO G, LONGO C, MOSCARELLA E, SPECCHIO F, RAUCCI M, ZALAUDEK I. The dermatoscopic universe of basal cell carcinoma. Dermatol Pract Concept [online] 2014 Jul, 4(3):11-24 [viewed 25 September 2014] Available from: doi:10.5826/dpc.0403a02
  2. WILLIAMS C, QUIRK C, QUIRK A. Melanoma: A new strategy to reduce morbidity and mortality. Australas Med J [online] 2014, 7(7):266-71 [viewed 25 September 2014] Available from: doi:10.4066/AMJ.2014.1949

Investigations - for Diagnosis

Fact Explanation
Biopsy of lesion A complete excisional biopsy is preferred. Incisional or punch biopsy suitable in large lesions and in lesions in cosmetically sensitive areas. [1],[2],[3],[5]
Fine needle aspiration If lymph node involvement is suspected clinically then the initial investigation should be with fine needle aspiration. [1],[2],[3],[4],[5]
Sentinal lymph node biopsy Sentinal lymph node is the first node to be involved in lymphatic spread. Sentinal biopsy is important to diagnostic, prognostic and therapeutic decision making. [1],[2],[3],[4]
Dermoscopy This is a non invasive technique for didtinguishing pigmented lesions in vivo. This is the first test to distinguish non melnocytic lesions, including sebrrhoic warts, haemangioma from melanocytic lesion. [6]
Full blood count and blood picture Full blood count and blood picture may show malignant changes. [1],[2],[3],[5]
Erythrocyte Sedimentation Ratio (ESR) Increased ESR value can be seen in malignant conditions. [1],[2],[3],[5]
References
  1. CHIARAVALLOTI AJ, LADUCA JR. Melanoma screening by means of complete skin exams for all patients in a dermatology practice reduces the thickness of primary melanomas at diagnosis. J Clin Aesthet Dermatol [online] 2014 Aug, 7(8):18-22 [viewed 25 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25161756
  2. SCOPE A, LONGO C. Recognizing the benefits and pitfalls of reflectance confocal microscopy in melanoma diagnosis. Dermatol Pract Concept [online] 2014 Jul, 4(3):67-71 [viewed 25 September 2014] Available from: doi:10.5826/dpc.0403a13
  3. MAVROGENIS A, BIANCHI G, STAVROPOULOS N, PAPAGELOPOULOS P, RUGGIERI P. Clinicopathological features, diagnosis and treatment of clear cell sarcoma/melanoma of soft parts. Hippokratia [online] 2013 Oct, 17(4):298-302 [viewed 25 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25031505
  4. MORTON DL, THOMPSON JF, COCHRAN AJ, MOZZILLO N, NIEWEG OE, ROSES DF, HOEKSTRA HJ, KARAKOUSIS CP, PULEO CA, COVENTRY BJ, KASHANI-SABET M, SMITHERS BM, PAUL E, KRAYBILL WG, MCKINNON JG, WANG HJ, ELASHOFF R, FARIES MB, MSLT GROUP. Final trial report of sentinel-node biopsy versus nodal observation in melanoma. N Engl J Med [online] 2014 Feb 13, 370(7):599-609 [viewed 25 September 2014] Available from: doi:10.1056/NEJMoa1310460
  5. MOREIRA J, MOREIRA E, AZEVEDO F, MOTA A. [Cutaneous malignant melanoma: a retrospective study of seven years (2006-2012)]. Acta Med Port [online] 2014 Jul-Aug, 27(4):480-8 [viewed 25 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25203957
  6. KARDYNAL A, OLSZEWSKA M. Modern non-invasive diagnostic techniques in the detection of early cutaneous melanoma. J Dermatol Case Rep [online] 2014 Mar 31, 8(1):1-8 [viewed 01 October 2014] Available from: doi:10.3315/jdcr.2014.1161

Investigations - Fitness for Management

Fact Explanation
Total protein and albumin Total protein and albumin provide an idea about nutritional level . It affects prognosis.[1],[2],[3]
Serum creatinine level Many chemotherapy drugs are renal toxic. Therefore baseline serum creatinine level must be chekced. [1],[2],[3]
References
  1. MOREIRA J, MOREIRA E, AZEVEDO F, MOTA A. [Cutaneous malignant melanoma: a retrospective study of seven years (2006-2012)]. Acta Med Port [online] 2014 Jul-Aug, 27(4):480-8 [viewed 25 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25203957
  2. MAVROGENIS A, BIANCHI G, STAVROPOULOS N, PAPAGELOPOULOS P, RUGGIERI P. Clinicopathological features, diagnosis and treatment of clear cell sarcoma/melanoma of soft parts. Hippokratia [online] 2013 Oct, 17(4):298-302 [viewed 25 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25031505
  3. WILLIAMS C, QUIRK C, QUIRK A. Melanoma: A new strategy to reduce morbidity and mortality. Australas Med J [online] 2014, 7(7):266-71 [viewed 25 September 2014] Available from: doi:10.4066/AMJ.2014.1949

Investigations - Followup

Fact Explanation
Follow up clinic visits Patients who have had melanoma should be screened for recurrence and metastasis. Recurrence usually appear as a growth or pigmentation at the site. In transit melanomas are satellite nodules nearby but not connected to original tumor. The regional lymph nodes should be palpated.[1],[2]
Lactate dehydrogenase level (LDH) LDH levels monitoring helps to identify recurrence and secondaries.[1],[2]
References
  1. RUTKOWSKI P, LUGOWSKA I. Follow-up in melanoma patients. Memo [online] 2014, 7(2):83-86 [viewed 01 October 2014] Available from: doi:10.1007/s12254-014-0151-y
  2. CURL P, VUJIC I, VAN 'T VEER LJ, ORTIZ-URDA S, KAHN JG. Cost-Effectiveness of Treatment Strategies for BRAF-Mutated Metastatic Melanoma. PLoS One [online] 2014, 9(9):e107255 [viewed 25 September 2014] Available from: doi:10.1371/journal.pone.0107255
  3. WILLIAMS C, QUIRK C, QUIRK A. Melanoma: A new strategy to reduce morbidity and mortality. Australas Med J [online] 2014, 7(7):266-71 [viewed 25 September 2014] Available from: doi:10.4066/AMJ.2014.1949

Investigations - Screening/Staging

Fact Explanation
Biopsy of lesion The most popular staging systems for melanoma are TNM classification (tumor, node, metastasis). The histology can be used to assess prognosis. Breslow's and Clark's methods are used to micro staging. Breslow's method is to measure, with an ocular micrometer, the vertical distance from granular cell layer to deepest part of the tumor. Clark's method used less frequently nowadays, is to assess the depth of penetration of melanoma in relation to layers of dermis. [1],[3],[5],[6]
Sentinal lymph node biopsy Sentinal lymph node biopsy provides information regarding lymph node involvement.[4],[5],[6]
Chest X-ray Chest X-ray is performed to identify lung metastasis. [2],[6]
Ultra sound scan Ultra sound scan is the best imaging study to identify lymph node metastasis. [2],[6]
PET/CT scanning PET/CT scanning is the best imaging study to identify other sites of metastasis. [2],[6]
Liver function tests Elevated levels of liver function tests [AST], [ALT] may indicates metastasis to the liver. [5],[6]
Lactate dehydrogenase level (LDH) An elevated alkaline phosphatase level may suggests metastasis to bone or liver. [5],[6]
References
  1. CHIARAVALLOTI AJ, LADUCA JR. Melanoma screening by means of complete skin exams for all patients in a dermatology practice reduces the thickness of primary melanomas at diagnosis. J Clin Aesthet Dermatol [online] 2014 Aug, 7(8):18-22 [viewed 25 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25161756
  2. RODRíGUEZ-MARCO N, CAICEDO-ZAMUDIO C, SOLANAS-ÁLAVA S, GIL-ARNAIZ I, CóRDOBA-ITURRIAGAGOITIA A, ANDONEGUI-NAVARRO J. [Whole body PET/CT imaging for detection of metastatic choroidal melanoma.] An Sist Sanit Navar [online] 2014 agosto, 37(2):293-298 [viewed 25 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25189988
  3. SCOPE A, LONGO C. Recognizing the benefits and pitfalls of reflectance confocal microscopy in melanoma diagnosis. Dermatol Pract Concept [online] 2014 Jul, 4(3):67-71 [viewed 25 September 2014] Available from: doi:10.5826/dpc.0403a13
  4. MORTON DL, THOMPSON JF, COCHRAN AJ, MOZZILLO N, NIEWEG OE, ROSES DF, HOEKSTRA HJ, KARAKOUSIS CP, PULEO CA, COVENTRY BJ, KASHANI-SABET M, SMITHERS BM, PAUL E, KRAYBILL WG, MCKINNON JG, WANG HJ, ELASHOFF R, FARIES MB, MSLT GROUP. Final trial report of sentinel-node biopsy versus nodal observation in melanoma. N Engl J Med [online] 2014 Feb 13, 370(7):599-609 [viewed 25 September 2014] Available from: doi:10.1056/NEJMoa1310460
  5. MAVROGENIS A, BIANCHI G, STAVROPOULOS N, PAPAGELOPOULOS P, RUGGIERI P. Clinicopathological features, diagnosis and treatment of clear cell sarcoma/melanoma of soft parts. Hippokratia [online] 2013 Oct, 17(4):298-302 [viewed 25 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25031505
  6. MOREIRA J, MOREIRA E, AZEVEDO F, MOTA A. [Cutaneous malignant melanoma: a retrospective study of seven years (2006-2012)]. Acta Med Port [online] 2014 Jul-Aug, 27(4):480-8 [viewed 25 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25203957

Management - General Measures

Fact Explanation
Educate the patient and family The breaking bad should be done in a sensitive and effective way. Explain to patient that melanoma is a skin cancer which can be treated successfully in many cases. Discuss about available treatment options, possible side effects. [1],[2],[3]
References
  1. WILLIAMS C, QUIRK C, QUIRK A. Melanoma: A new strategy to reduce morbidity and mortality. Australas Med J [online] 2014, 7(7):266-71 [viewed 25 September 2014] Available from: doi:10.4066/AMJ.2014.1949
  2. MAVROGENIS A, BIANCHI G, STAVROPOULOS N, PAPAGELOPOULOS P, RUGGIERI P. Clinicopathological features, diagnosis and treatment of clear cell sarcoma/melanoma of soft parts. Hippokratia [online] 2013 Oct, 17(4):298-302 [viewed 25 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25031505
  3. CURL P, VUJIC I, VAN 'T VEER LJ, ORTIZ-URDA S, KAHN JG. Cost-Effectiveness of Treatment Strategies for BRAF-Mutated Metastatic Melanoma. PLoS One [online] 2014, 9(9):e107255 [viewed 25 September 2014] Available from: doi:10.1371/journal.pone.0107255

Management - Specific Treatments

Fact Explanation
Surgical excision Surgical excision, with minimal delay, is required. A minimal of 0.5cm clearance for melanomas insitu and 1cm clearance is required in invasive melanomas. Nowadays many surgeons excise 1cm of normal skin around the tumor for every millimeter of tumor thickness, up to 3mm. [1],[2],[3],[4],[5]
Lymph node dissection Patients with lymphadenopathy with no evidence of distant metastasis must undergo complete regional lymph node dissection. [1],[2],[3],[4],[5]
Chemotherapy In treatment of advanced stage melanoma combination regimens are used. Cisplatine, Vinblastine, DTIC , Carmustine & Tamoxiten are included in commonly used regimens. [1],[2],[3],[4],[5]
Radiotherapy External beam radiation is effective in brain metastasis. [1],[2],[3],[4],[5]
Immunotherapy Interferon alpha is used for adjunctive therapy after excision who have high risk of recurrence. Granulocyte - macrophage colony stimulating factor used to adjunctive therapy to treat melanoma of stage III and IV . [1],[2],[3],[4],[5]
Vaccines Treatment with melanoma specific antigen vaccines has a role as adjunct to surgery in patients at TNM stage 11 and 111. [1],[2],[3],[4],[5]
References
  1. TOMEI S, BEDOGNETTI D, DE GIORGI V, SOMMARIVA M, CIVINI S, REINBOTH J, AL HASHMI M, ASCIERTO ML, LIU Q, AYOTTE BD, WORSCHECH A, UCCELLINI L, ASCIERTO PA, STRONCEK D, PALMIERI G, CHOUCHANE L, WANG E, MARINCOLA FM. The immune-related role of BRAF in melanoma. Mol Oncol [online] 2014 Aug 6 [viewed 25 September 2014] Available from: doi:10.1016/j.molonc.2014.07.014
  2. TRONNIER M, MITTELDORF C. Treating advanced melanoma: current insights and opportunities. Cancer Manag Res [online] 2014:349-56 [viewed 25 September 2014] Available from: doi:10.2147/CMAR.S49494
  3. CURL P, VUJIC I, VAN 'T VEER LJ, ORTIZ-URDA S, KAHN JG. Cost-Effectiveness of Treatment Strategies for BRAF-Mutated Metastatic Melanoma. PLoS One [online] 2014, 9(9):e107255 [viewed 25 September 2014] Available from: doi:10.1371/journal.pone.0107255
  4. MORTON DL, THOMPSON JF, COCHRAN AJ, MOZZILLO N, NIEWEG OE, ROSES DF, HOEKSTRA HJ, KARAKOUSIS CP, PULEO CA, COVENTRY BJ, KASHANI-SABET M, SMITHERS BM, PAUL E, KRAYBILL WG, MCKINNON JG, WANG HJ, ELASHOFF R, FARIES MB, MSLT GROUP. Final trial report of sentinel-node biopsy versus nodal observation in melanoma. N Engl J Med [online] 2014 Feb 13, 370(7):599-609 [viewed 25 September 2014] Available from: doi:10.1056/NEJMoa1310460
  5. MAVROGENIS A, BIANCHI G, STAVROPOULOS N, PAPAGELOPOULOS P, RUGGIERI P. Clinicopathological features, diagnosis and treatment of clear cell sarcoma/melanoma of soft parts. Hippokratia [online] 2013 Oct, 17(4):298-302 [viewed 25 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25031505