In this article we will tell and show what nodular melanoma looks like and how to treat it.
For nodular melanoma, the extended ABCDE rule is used, to which the letters EFG are added.
E - Elevated. Benign lesions can be elevated (e g, a dermal naevus, dermatofibroma, or cyst), but a new elevated or thickened lesion may be suspicious for nodular melanoma or another form of skin cancer.
F - Firm. Benign lesions can feel firm (especially dermatofibroma), but this is also a feature of nodular melanoma.
G - Growing. A nodular melanoma tends to grow rapidly with changes noted over days or weeks. Benign skin lesions tend to remain stable or change slowly over years to decades. Although they can rapidly change in appearance over hours to days if injured, inflamed, bleeding, or affected by eczema, they do not usually grow in size.
It is also worth noting that the malignant formation often loses its characteristic skin pattern, becomes smooth and shiny.
In nodular melanoma, melanoma cells proliferate downwards through the skin – this is known as vertical growth. The lesion presents as a nodule (lump) that has been rapidly enlarging over the previous weeks to months. It can arise de novo in normal-appearing skin, or within an existing melanoma of another type.
Nodular melanoma can penetrate deep within the skin within a few months of its first appearance.
Who gets nodular melanoma? Nodular melanoma accounts for about 15% of all melanoma cases. Although more common in very fair skin (skin phototype 1 and 2), it may also occur in those who tan quite easily (phototype 3), and occasionally in brown or black skin (phototype 4-6).
Nodular melanoma is more common in males than in females. Most are over the age of 50 when it is diagnosed.
It is less strongly associated with sun exposure than superficial spreading and lentigo maligna types of melanoma.
What does nodular melanoma look like?
Nodular melanoma may arise on any site but is most common on exposed areas of the head and neck.
Nodular melanoma presents as a rapidly enlarging lump (over several weeks to months). The characteristics of nodular melanoma include:
Larger size than most moles >6 mm and often a centimetre or more in diameter at diagnosis
Dome-shaped, often symmetrical firm lump
Single colour or variable pigmentation – most often black, red or skin coloured
Smooth, rough, crusted or warty surface
Ulceration or bleeding
Itching or stinging
One-third of nodular melanomas are not pigmented. They lack the ABCDE criteria melanoma warning signs. (Asymmetry, Border irregularity, Colour variation, large Diameter).
What is the cause of nodular melanoma?
Nodular melanoma is due to the development of malignant pigment cells (melanocytes) along with the basal layer of the epidermis. These cells may occasionally arise from an existing melanocytic naevus (about 3%) but commonly occur within another type of melanoma or in previously normal-appearing skin. What triggers the melanocytes to become malignant is unknown, but it is likely to be a series of changes to the DNA. NRAS mutations are often found in patients with nodular melanomas.
What is the treatment for nodular melanoma?
The initial treatment of primary melanoma is to cut it out; the lesion should be completely excised with a 2-3 cm margin of normal tissue. Further treatment depends mainly on the Breslow thickness of the lesion.
What happens at follow-up of melanoma?
The primary purpose of follow-up is to detect recurrences early, but it also offers an opportunity to diagnose a new primary melanoma at the first possible opportunity. A second invasive melanoma occurs in 5-10% patients; an unrelated melanoma in situ affects in more than 20% of melanoma patients.
Routine skin checks by a patient's preferred health professional
Follow-up intervals are preferably six-monthly for five years for patients with stage 1 disease, three-monthly or four-monthly for five years for patients with stage 2 or 3 disease, and yearly after that for all patients.
Individual patient’s needs should be considered before an appropriate follow-up is offered
Provide education and support to help the patient adjust to their illness
The follow-up appointments may be undertaken by the patient's general practitioner or specialist, or they may be shared.
Follow-up appointments may include:
A check of the scar where the primary melanoma was removed
In those with more advanced primary disease, follow-up may include:
Blood tests, including LDH
Imaging: ultrasound, X-ray, CT, MRI and PET scan.
Tests are not typically worthwhile for stage 1/2 melanoma patients unless there are signs or symptoms of disease recurrence or metastasis. And no tests are thought necessary for healthy patients who have remained well for five years or longer after removal of their melanoma, whatever stage.
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