- CLINICAL DIAGNOSIS OF MELANOMA
- SURFACE MICROSCOPY
- SCREENING AND SURVEILLANCE
- FAMILIAL RISK AND FAMILY SURVEILLANCE
- BIOPSY OF PIGMENTED LESIONS
- CONGENITAL MELANOCYTIC NAEVI
- LENTIGO MALlGNA
- HISTOPATHOLOGICAL REPORT
- CLASSIFICATION OF MELANOMA
- TREATMENT OF PRIMARY MELANOMA
- SURVIVAL OUTCOMES OF PRIMARY MELANOMA MANAGEMENT
- TREATMENT OF LYMPH NODES
- OCCULT PRIMARY MELANOMA
- LOCOREGIONAL RECURRENT MELANOMA
- ADJUVANT THERAPY
- DISSEMINATED MELANOMA
- RADIOTHERAPY FOR MELANOMA
- PALLIATIVE CARE
- FOLLOW UP
- APPROPRIATE INVESTIGATIONS
- SPECIFIC SITES AND TYPES OF MELANOMA
Dagmar K. Whitaker M.D. Dermatologist; Werner Sinclair M.Med
Dermatologist; Daniel Vorobiof M.D. Oncologist; Graham Cohen FCP(SA) Medical
Oncologist; David Presbury FRCP Dermatologist; Peter Scott FRCS Plastic
Surgeon; Helen Stubbings Oncologist; Charles Thatcher FFPath Pathologist; Prof
A. Giraud FRCS General Surgeon; Brian Ritchie FRCS Plastic Surgeon; Constant
Nel Oncologist; Gary Levy FFDerm Dermatologist
Invasive primary malignant melanoma in whites shows the greatest and most rapid
increase of all cancer worldwide. The incidence in South Africa is unknown but
what is known is that the incidence in the Cape Town area is similar to that of
Australia (24.4 per 100,000) and epidemiological studies, to determine the
exact incidence are in progress. In Australia it is one fo the most common
cancers 1-3 with the estimated risk of developing a melanoma before the age of
75 (in 1993) being 1 in 27 for males and 1 in 36 for females.3
Melanoma is therefore an important clinical and health problem and it is
essential that the management of the disease is as effective as possible. These
clinical practice guidelines are designed to assist those involved in the
management of this common cancer to provide optimum management for their
patients. They are based on the guidelines developed and published by the
Australian Cancer Network 4 and have been summarised and adapted as follows.
Exposure to sunlight is strongly associated with the development of melanoma.5
The pattern of exposure is important, with intermittent exposure being more
closely linked to the development of melanoma than the regular patterns of
exposure of the outdoor worker.5 The action spectrum, which is
causative for melanoma, in particular the relative roles of UVB and UVA, is as
yet unknown. However in animal models, UVA has been found to be a highly
significant component in melanoma induction.6,7 In addition the use
of sunbeds which deliver mainly UVA radiation may be arisk factor for melanoma.8
The following protection measures are recommended:
Physical protection should be the primary preventative measure. Avoid direct
exposure to sunlight during the two hours either side of solar noon.
Use sun protective clothing when exposed to direct sunlight for periods greater
than 15 minutes.
People should be advised to choose dark clothing of closely woven fabrics which
is more protective than light loosely woven garments. Fabrics with an inbuilt
protection factor are available in i.e. sports/diving/climbing shops.
Use broad spectrum sunscreens as an adjunct to sun avoidance and other sun
protective measures. New sunscreens should contain a UVA as well as UVB screen
and in contrast to previous recommendations that a factor 15 is adequate the
advise is : The higher the factor the better (> SP30).
Provide and use sun protective structures (eg. shade structures) whenever
Provide children with appropriate sun protection for outdoor activities.
Emphasis should be placed on the protection of children and adolescence from
excessive sunlight exposure.9 Sunlight exposure at this age is closely related
to the development of naevi. The presence of multiple naevi is a strong risk
factor for melanoma.10-14
Advise against the use of sunbeds, tanning booths and tanning lamps. These
deliver mainly UVA radiation and UVA radiation causes DNA mutation which is a
predisposing factor for subsequent carcinogenic UVB damage.
The dignosis of melanoma should be considered in all cases of
pigmented or chainging lesions on the skin. The key to the clinical diagnosis
of a pigmented melanoma is irregularity of the lesion. Irregularity of colour
is most important and the presence of a variet of colours in any one lesion is
a key feature. While a black or blue/black colour is the most common, many
other shades of brown, blue, red, grey or white are often seen. Irregularity of
outline is the second most common feature with indentations and outgrowths
around the lesion often apparent. Irregularity of the surface is another
important sign. Amelanotic melanoma is clinically difficult to diagnose,
usually appearing as an enlarging smooth reddish nodule or patch. Sometimes an
area of brown pigment can be discerned in these lesions. Surface microscopy may
CLINICAL DIAGNOSIS OF MELANOMA
The ABCDE system of diagnosis of melanoma has gained general support.17,18
A = ASYMMETRY
A lesion is asymmetric if opposite segments of the lesion are appreciably
B = BORDER
The border of a melanoma is usually irregular, resembling a coastline with bays
and promontories around the edge. All or part of the border is often well
defined, in contrast with the dysplastic naevus, whose border is often
ill–defined and fades into the background of the surrounding tissues.
C = COLOUR
Variation in colour is an important feature. A narrow red halo is sometimes
seen around the edge of a melanoma. It is important to remember that amelanotic
melanoma will have little or no distinguishing colour.
D = DIAMETER
Superficial spreading melanomas are often greater than 6mm in diameter when
first diagnosed, but it is possible to diagnose smaller melanomas, particularly
nodular lesions, which appear not only as small shiny dark nodules but can also
be reddish in amelanotic forms.
E = ELEVATION
While E designates elevation, it is important to diagnose melanoma while it is
flat or with marginal elevation. At that stage the lesion is more likely to be
curable. Thus E should remind the clinician to ‘Examine’ the patient’s other
A feature which may be helpful in diagnosing melanomas is a ‘ground glass’
amorphous appearance to part of the lesion. Where the skin lines have been
destroyed by the tumours, a shiny, glassy appearance is noted. Many melanomas
will also have small flakes of keratin on the surface but it is extremely rare
for the lesion to be extensively keratinised. The presence of hairs does not
exclude a diagnosis of melanoma, but most pigmented lesions with hairs are
benign. However, more advanced melanomas will not have hair in the deeply
invasive parts of the tumour because the melanoma will destroy the hair
follicles as it invades. Thick melanomas are firm to touch and not
compressible, unlike haemangiomas, and are rarely waxy to feel, unlike a
The differential diagnosis of pigmented melanoma includes dysplastic naevus,
Spitz naevus, pigmented basal cell carcinoma, blue naevus, haemangioma,
pigmented seborrhoeic keratosis and some rare adnexal tumours. In children,
pigmented Spitz naevus is a likely diagnosis.
The amelanotic or hypomelanotic tumour differential diagnosis includes
dermatofibroma, desmoplastic melanoma, basal cell carcinoma and other spindle
Good lighting and magnification is recommended when lesions are being examined.
All clinicians should become trained in the recognition of early melanoma.
A good clinical history of change in the lesion, if any, a past history of skin
lesions, and a family history of melanoma should be obtained. A family history
is defined as melanoma in a direct line family member -grandparent, parent,
sibling or child of the patient.
Refer for a specialist opinion or biopsy lesions which are suspicious. High
risk individuals should be advised on the specific changes which suggest
melanoma and encouraged to undertake self examination.
Take note of any recent change or sensation reported by the patient.
Skin surface microscopy should be carried out by Specialists who have had
specific training and are experienced due to the highly specialised nature of
this examination. (Dermatoscope) 19-23
Digital Epiluminescence Microscopy (Molemax) can be used to monitor high risk
patients because it allows to view morphological features (colours,
pigmentation pattern) not seen with traditional surface microscopy and it is an
effective documentation system.
Risk factors for development of melanoma include a family
history of melanoma, fair complexion, a tendency to burn rather than tan, the
presence of freckles, the presence of solar lentigines, light eye colour, light
or red hair colour and a past history of non-melanoma skin cancer. 24-26
SCREENING AND SURVEILLANCE
All individuals who are at high risk for the development of melanoma should be
advised about the changes that might suggest the development of an early
melanoma, encouraged to undertake regular self examination and advised
regarding appropriate methods of sun protection.
The presence of large numbers of melanocytic naevi and the presence of
clinically determined atypical or dysplastic naevi are very strong risk factors
for melanoma.13, 24-27 Dysplastic naevi are generally larger than
normal moles with ill-defined edges and irregular pigmentation, which is mostly
shades of brown.28 They tend to have a poorly defined edge.28
Melanoma risk increases with increasing numbers of total naevi and dysplastic
naevi.13,24-27 The risk associated with clinical dysplastic naevi
has been shown to be independent of that associated with the total numbers of
naevi.27 Clinically dysplastic naevi are not always dysplastic on
Prophylactic excision of dysplastic naevi and other benign naevi is not useful
in minimizing melanoma risk. A significant proportion of melanomas begin as new
lesions rather than developing from pre-exsiting naevi.29-31
Consider referral of these high risk individuals a specialist with an interest
in melanoma management
FAMILIAL RISK AND FAMILY
Recent Australian data indicate that 10% of melanoma cases will have at least
one (and most only one) confirmed melanoma-affected first degree relative 32,
potentially resulting from inheritance of uncommon, major melanoma
susceptibility gene(s). 33 Consider referral of family members with a strong
history of melanoma among close relatives, particularly with large numbers of
naevi, to a specialist with interest in melanoma management and refer for
genetic studies if available.
BIOPSY OF PIGMENTED LESIONS
Biopsy of pigmented lesions should be done only on the basis of suspicious
clinical features. Prophylactic excision of clinically benign lesion is not
recommended. Primary biopsy should always be performed by complete excision.
Shave and punch biopsies of pigmented lesions should be avoided
Lesions suspected to be melanoma should be excised with a 2 mm lateral margin
and to the depth of the upper layer of the fat.
Where doubt exists, a period of observation based on the history and clinical
features of the lesion is acceptable. The period of observation will be short
if a high level of suspicion of melanoma is present. However, if the clinician
feels the lesion is unlikely to be melanoma and it does not change, it is
appropriate to continue observation until the evidence of change appears.
If melanoma is suspected, referral for a specialist opinion, where available
should be considered before biopsy is undertaken.
CONGENITAL MELANOCYTIC NAEVI
Congenital naevi are present at birth and are diagnosed with specific
histological features.34-36 The lesions are arbitrarily divided into
three groups based on diameter: <1.5 cm, 1.5–20 cm and 20+ cm.
SMALL(<1.5 cm) lesions occur in 1% of births. They are not thought to have
an increased malignant potential. 31-36
MEDIUM (1.5 – 20 cm) lesions have not been subject to adequate research so the
malignant potential of this group is unclear. 37-38 If excision is
undertaken, it should be during the teenage years, since a study of 31 patients
with melanomas arising from small congenital naevi (1.5–10cm) found none of
these melanomas presenting before puberty. However, at this stage, the body of
evidence suggests that observation only is required.
LARGE(>20 cm) lesions. There are only two prospective studies addressing
these lesions. These show a crude risk of 3%. 39-41 A literature
review 8 has shown that 70% of melanomas in this group develop before puberty.
Superficial removal of the naevus by dermabrasion or tangential excision is not
recommended as two-thirds of melanoma develop in non-epidermal sites. 42,43
Patients with large congenital naevi of the head and neck are also at risk from
neurocutaneous melanosis. 44
An MRI scan should be considered for screening these patients. 45 Lifelong
surveillance for large and possibly for medium congenital naevi is recommended.
The removal of large naevi for cosmetic reasons only has no contra-indications
provided the patient is made fully aware of the likely appearance of the end
Excisional biopsy of suspicious areas in large congenital naevi is recommended
but should be carried out at a specialist centre.
Surgical excision of congenital naevi is appropriate where patient concern is
high and where an acceptable cosmetic outcome can be achieved.
Lentigo maligna (Hutchinson’s melanotic freckle) is a common pigmented lesion
on the exposed skin of the older patient. These lesions are regarded as in-situ
melanoma and may progress to invasive melanoma (lentigo maligna melanoma) in
many people, and so must be managed carefully. These lesions occur
predominantly on the face.
Biopsy is indicated for changing pigmented lesions on the face.
Where lentigo maligna is histologically confirmed, complete excision is the
For some patients, treatment by observation for change, with measurement, is an
acceptable alternative to immediate excision
A Wood light is helpful to determine the extent of the lentigo maligna.
Cryotherapy and shave biopsies should be left to the discretion of a
An accurate histopathology report is an essential prerequisite
for optimal therapy for melanoma.
Request forms for pathology should include adequate patient identification, and
clinical details of all lesions removed.
Where more than one lesion is excised, separate specimen bottles are essential.
The pathologist's report should include all important features of the lesions.
(Histopathologic Type, Tumor thickness and ulceration)
Tumour thickness, ulceration and clearance margins are essential. A
standardised format of histological reporting on melonoma is advocated
Where clinical and pathological diagnoses do not concur, a second opinion
should be sought from a pathologist with expertise in the diagnosis of
Use of the AJCC/UICC classification system (2002) is
CLASSIFICATION OF MELANOMA
The primary tumour categories in the TNM classification are based on 2
microstaging systems: 1. Clark system – describes the level of
microinvasion through the layers of the dermis. This is now mainly of historic
value and relevant only for very thin melanomas. It gets replaced by the
Breslow thickness – which is considered the most important diagnositc factor
for primary melanoma. The thickness is measured in millimetres from the
granular cell layer to the base of the lesion and is divided into 4 groups:
> 1.50- 4 mm;
> 4 mm.
||Primary tumor cannot be assessed (e.g., shave biopsy or regressed
||No evidenceof primary tumor
||Melanoma in situ
||Melanoma < 1.0 mm in thickness with or without ulceration
||Melanoma < 1.0 mm in thickness and level II or III, no
||Melanoma < 1.0 mm in thickness and level IV or V with ulceration
||Melanoma 1.01 – 2 mm in thickness with or without ulceration
||Melanoma 1.01 – 2.0 mm in thicknss, no ulceration
||Melanoma 1.01 – 2.0 mm in thicknss, with ulceration
||Melanoma 2.01 – 4 mm in thickness, with or without ulceration
||Melanoma 2.01 – 4.0 mm in thickness, no ulceration
||Melanoma 2.01 – 4.0 mm in thickness, with ulceration
||Melanoma greater than 4.0 mm in thickness with or without
||Melanoma > 4.0 mm in thickness, no ulceration
||Melanoma > 4.0 mm in thickness, with ulceration
|N.B Note that Clarke level is only important for thin
|Regional Lymph Nodes (N)16
||Regional lymph nodes cannot be assessed
||No regional lymph node metastsis
||Metastasis in one lymph node
||Clinically occult (microscopic) metastasis
||Clinically apparent (macrospopic) metastasis
||Metastasis in two to three regional nodes or intra-lymphatic
regional metastasis without nodal metastases
||Clinically occult (microscopic) metastasis
||Clinically apparent (macroscopic) metastasis
||Satellite or in-transit metastasis without nodal metastasis
||Metastasis in four or more regional nodes, or mated metastatic
nodes, or in-transit metastsis or satellite(s) with metastasis in regional
|Distant Metastasis (M)16
||Distant metastasis cannot be assessed
||No distant metastasis
||Metastasis to skin, subcutaneous tissues or distant lymph nodes
||Metastasis to lung
||Metastasis to all other visceral sites or distant metastasis an any
site associated with an elevated secrum lactic dehydrogenase (LDH)
TREATMENT OF PRIMARY MELANOMA
The AJCC/UICC system (2002) is recommended as the basis for melanoma therapy.16
Complete excision with margins determined by tumour thickness measurement
should be the basis for management of primary melanomas
A minimum margin of 1 cm and a maximum margin of 3cm should be used for
invasive melanoma, with a choice of excision margin determined by tumour
thickness. A depth of excision equal to the margin is advised but is not
necessary to excise further than the deep fascia.
Other pathological features should be used to make an assessment of prognosis
and modify management decisions In very thin lesions, thickness alone does not
accurately predict the prognosis.
|The following is recommended 46-49
||Melanoma in situ
||-margin 1 cm
||-minumum margin 1cm
and maximum margin 2cm
||Melanoma > 4.0mm
||-minimum margin 2cm
and maximum margin 3cm
|It should be notes that there is no evidence that a
margin greater than 1cm offers additional benefit to the patient in terms of
survival but it may decrease local recurrence.47-50
Primary lesions in special sites should be referred to a specialist centre
SURVIVAL OUTCOMES OF
PRIMARY MELANOMA MANAGEMENT
Survival after diagnosis of melanoma falls with increasing tumour
thickness.51-52 To advise patients on the likely outcome of their primary
melanoma management, the following estimates may be given for 5 year survival
rates from the AJCC 2002:
Five-year survival rates of pathologically staged patients (adapted from Blach
Other prognostic variables influence outcomes. Such factors as a thin melanoma
which reaches Clark level 4, ulceration, the presence of lymphatic invasion,
satellites and high mitotic rate may adversely affect the prognosis for the
individual patients with melanoma.53,54
TREATMENT OF LYMPH NODES
All patients with invasive melanoma are at risk for metastases to the lymph
nodes. Metastases to lymph nodes are uncommon for melanomas <1.0mm in tumour
thickness. For primary melanomas 1.0mm and greater in thickness, an increasing
proportion of patients will develop regional lymph node involvement. At least
25% of melanomas between 1.5mm and 4.0mm thick will have microscopic lymph node
involvement at the time of primary diagnosis. Sixty per cent of melanomas
thicker than 4.0mm will have nodal involvement 55-57, but these involved nodes
are usually not clinically apparent at the time of primary diagnosis.
Needle aspiration is preferable to excision biopsy of lymph nodes suspicious of
metastatic melanoma.51 This should only be performed by doctors who
are thoroughly familiar with the technique. If the local radiologist has
expertise in UIS of nodes then it may be appropriate to do U/S and proceed
directly to a block dissection if nodes are suspicious.
Excision biopsy of suspicious nodes should be followed by node dissection
immediately if nodal metastases are detected.51
Elective lymph node dissection is generally not recommended.58-62,63-66
Therapeutic node dissection should be undertaken only by surgeons traines in
these procedures. 67,68,69-74
The recent surgical technique of lymphatic mapping and selective node biopsy
provides an alternative approach to the treatment of melanoma >1mm thick.
69-71 Sentinel node biopsy means identification of the first lymph nodes (the
sentinel nodes) to take up radioactive tracer injected around a primary site.
These nodes are then marked on the skin and identified at surgery by injection
of patent blue dye. The blue stained nodes are selectively biopsied and
examined by histology and immune histochemistry. Should they be positive the
lymph nodes get dissected. This ensures that patients with nodal involvement
are subjected to full regional lymph node dissection.
Sentinel node biopsy should only be performed by surgeons trained in this
Adequate node dissection is associated with a reasonably good prognosis, with a
10-year survival of up to 50% where only one node is involved. Even when two or
three nodes are involved, 10-year survival rates of up to 30% can be achieved.
51 However, extranodal spread is associated with a high fatality rate, and
radiotherapy could be considered if this is detected, if the nodes are
extensively involved or if tumour spillage occurs during the surgery.
CT scans could be used to assess the iliac nodes where inguinal lymph node
dissection is contemplated.
OCCULT PRIMARY MELANOMA
Melanoma in lymph nodes or systemic metastases should be treated in accordance
with guidelines regardless of the inability to detect the primary lesion.75-78
LOCOREGIONAL RECURRENT MELANOMA
Excision of a single local or regional metastasis is the treatment of choice.
Limb perfusion in a specialised centre should be considered if satellite
lesions are present. 79-82
Patients with melanomas >4mm thick or with lymph node metastases should be
referred to a specialised centre for consideration for adjuvant therapy.
Patients with systemic metastases should be referred to a specialised centre
for consideration for systemic therapies.
All clinicians dealing with patients with systemic melanoma should be
appropriately skilled in psychological management and palliative care.83-85
Surgical resection should be considered for isolated melanoma metastases in
lung, brain and peritoneal cavity.86 Multiple subcutaneous metastases may be
well controlled with surgery in some cases if the patient is followed up
RADIOTHERAPY FOR MELANOMA
Post-operative radiotherapy could be considered for cutaneous melanomas likely
to recur e.g. where wide resection of the primary tumour is not feasible, as
sometimes happens on the face. 87
or regionally (multiple node involvement or extra-capsular spread) and
following resection of mucosal melanomas. Primary radiotherapy should be
considered for unresectable lentigo maligna melanomas or large unresectable
primary lesions in the elderly and frail. 87
Radiotherapy may be recommended for treatment of extensive cutaneous metastases
where surgery is not feasible and for palliative management of cerebral and
bone metastases and for other metastases where temporary local control is
needed eg. large nodal or soft tissue masses.88-91
Educating patients and carers as to the behaviour of metastatic melanoma with
its unique features (i.e. subcutaneous spread and acute episodes of pain due to
bleeding) and the appropriate intervention will assist them in coping with the
Clinicians should be aware of the palliative care services available within the
patient's community, so that referral can be made if the patient so wishes
A follow-up regimen based on tumour thickness should be arranged for all
patients with melanoma.92,93
The follow-up examination should include palpation for local recurrence,
in-transit and lymph node metastases and signs of systemic relapse .A general
examination of the skin for new primary melanomas and other skin cancers should
Extensive investigation for systemic metastases in patients with primary
melanoma is not recommended. 94-96 Baseline investigations such as a FBC, CXR
and liver functions, including LDH, may be undertaken. Patients with deep
lesions should have a CT chest and upper abdomen. The latter may serve as a
baseline for future comparison.
Generally investigation such as MRI and PET (Position Emission Tomography)
should be utilised only where specific symptoms suggest the presence of
Mucosal melanoma is rare, comprising <1% of all melanoma. It occurs in the
mouth, nose, oesophagus, gall bladder, urethra, anus, vulva and vagina, and is
usually asymptomatic. 97,98 For this reason mucosal melanoma is generally
detected late and thus has a very poor prognosis. 99
SPECIFIC SITES AND TYPES OF MELANOMA
Patients with mucosal melanoma should be referred to a suitable speciality
clinic or clinician.
Acral Lentiginous Melanoma (ALM)
Acral lentiginous melanoma is defined as melanoma of the acral skin, i.e. the
thickened skin of the soles and palms. The main interest of the ALM
classification is that it is the predominant melanoma of non-white individuals.
Its prognosis may be marginally worse than other melanomas but this is yet to
be conclusively proven. 100-102
ALM on the sole of the foot should be referred for specialist excision and
appropriate reconstructive procedures and therapies.
Subungual melanoma should be considered as a possible cause of any pigmentary
changes under the nail. 103 In cases of doubt, removal of the nail and biopsy
is recommended. 104-106 Subungual melanoma should be treated with excision
margins which accord to the lesion thickness. This usually involves amputation
of the terminal phalanx. 104 Because most subungual melanomas are advanced at
the time of presentation, elective node dissection may be apprpriate for these
patients. 107,108 Naevi on the soles of the feet or on the genitals of patients
should not be removed routinely, because the incidence of malignant
transformation of the theses lesions is not higher than that of other lesions.
Desmoplastic and neurotropic melanomas are associated with a high risk of local
recurrence related to their poorly defined clinical borders, frequent
amelanosis and infiltration along nerve sheaths, predisposing to incomplete
excision and persistence of the primary tumour. 109,110
Wider excision than is normal for other histological types of melanoma is
recommended for Desmoplastic Melanoma. Post operative radiotherapy, in
consultation with a specialist should be considered after surgical excision of
a recurrent Desmoplastic or Neurotropic Melanoma.
Multiple new primary melanomas may occur in at least 5% of patients with
melanoma. 111-113 They are more common in patients with multiple atypical naevi
especially in a familial melanoma setting but can occur in any patients who has
had a melanoma.114-115
Multiple Primary Melanoma
Multiple Primary Melanoma should be treated according to the tumour thickness
of each lesion. 116
Melanoma is rare in children below the age of 12, but clinical features are
identical to those in the adult. 116
Melanoma in children should be treated as appropriate for the same tumour
thickness as melanoma in the adult. 117-118
Melanoma in a pregnant woman should be treated according to the tumour
thickness. 119-121 It has not been conclusively demonstrated that pregnancy
alters the prognosis in a patient who has a melanoma diagnosed either before or
during pregnancy. 120 Pregnant women with thicker melanomas and nodal
metastases should be treated in consultation with specialised centres and
psychological support may need to be obtained. Because of the possibility of
metastatic recurrence, pregnancy is not advisable for two years after removal
of high risk primary melanoma or melanoma in nodes. 122 Termination of
pregnancy should be considered in women with high risk primary or recurrent
melanoma only after detailed discussion with the patient and her partner.
Melanoma During Pregnancy
Hormone replacement therapy and oral contraceptives are not contraindicated for
women who have or have had melanoma. 123,124
Hormone Replacement Therapy and Oral Contraceptives
Disclaimer: This document is a general guide to appropriate practice, to be
followed only subject to clinicians judgement in each individual case. It is
compiled by Members of the Melanoma Advisory Board, a multidisciplinary forum
consisting of Dermatologists, Oncologists, Plastic Surgeons and Pathologists.
The guidelines are designed to provide information to assist decision making
and are based on the best information available at the date of compilation