Alberto Pappo, MD: Why Pediatric Melanoma Diagnosis Is In Flux

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The St. Jude oncologist discusses the 30-year development of pediatric melanoma interpretation.

The concept of pediatric melanoma has evolved in the last 3 decades, one expert told HCPLive. In the early 1990s, every lesion that was possibly melanoma in a child was treated as such, Alberto Pappo, MD, explained.

“We did extensive surgeries to access the status of the lymph nodes, then we gave adjuvant therapies…but over time we have learned there’s this spectrum that goes over the so-called pediatric melanoma,” he said.

In an interview with HCPLive during the Society for Pediatric Dermatology (SPD) 2022 Pre-AAD Meeting in New Orleans this year, Pappo, director of the Solid Tumor Division at St. Jude Children’s Research Hospital, discussed the development of pediatric melanoma diagnosis and treatment over 30 years—to its current state as a still-contested topic.

“We now know to reach the appropriate and right diagnosis, we need to use a series of facts that include not only the clinical history and the histopathologic diagnosis, but also add genomic information to come up with the best diagnosis possible,” Pappo said. “The reason why that is relevant is because you don’t want to subject a young child to unnecessary surgeries or give adjuvant therapies that are not necessary.”

The vast majority of pediatric melanoma cases are spitzoid melanocytomas among patients ≤10 years old, Pappo said. Despite high incidence of involvement of lymph nodes among lesions, they generally do not metastasize beyond the lymph node. Now there’s also understood genetic abnormalities including “fusions” that can help identify cases. While the modern care team has been solidified to include a primary care referral to dermatology, where they often receive a shave biopsy, there remains issues as to who appropriately assesses the biopsy.

“We have had patients who have had their pathology specimens sent out to 3, 4, 5 different places because nobody can come to an agreement, and then ultimately come to us and we do a thorough pathology review,” Pappo said.

What’s more, there remains little distinction between the available guidelines for adult melanoma versus pediatric spitzoid lesion detection. “There are a couple of consensus papers published recently, but if you read them they basically go back to, ‘The adults do this, so we should do this’,” Pappo added.

One thing that’s clear in pediatric melanoma detection, however: parent and guardian concern should always start the process.

“One hundred percent of the time, the parents are right, and we should not ignore what they say,” Pappo said. “If they see that the lesion is growing, changing color or is bleeding, they’re not making it up and they have a true concern.”