Pigmented Lesions Clinic: A Coordinated Approach to Pediatric Melanoma, MelTUMPS

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Oncology Update

As more children present with skin lesions that may have potential for malignancy, The Children’s Hospital of Philadelphia has formed a team to provide a consistent, multidisciplinary approach to evaluation and care.

Some of the increase in suspicious skin lesions in children and adolescents may be due to an increase in visits to dermatologists because of parents’ heightened awareness of the dangers of sun damage and the risk of melanoma. However, the rise in cases also reflects a true rise in incidence, just as in the adult population. Between 1973 and 2009, the incidence of pediatric melanoma increased by approximately 2 percent per year.

Melanoma in children and adolescents is still rare, occurring in 5 children per 1 million individuals. In the United States, approximately 350 children and adolescents less than 18 years of age are diagnosed with melanoma each year, comprising less than 1% of all cases of melanoma. Adolescents account for 75 percent of newly diagnosed melanoma in the pediatric population.

Elizabeth Fox Elizabeth Fox, MD Pediatric dermatologist Melinda Jen, MD, and pediatric oncologist Elizabeth Fox, MD, lead CHOP’s Pigmented Lesions Clinic. This newly formed team offers a comprehensive multidisciplinary approach, including specialists in pediatric dermatopathology, general surgery, and plastic surgery. The goal of this team is to provide comprehensive evaluations to aid in classification and management of pediatric melanoma and melanocytic tumors of uncertain malignant potential (MelTUMP). For those very rare cases when a child or adolescent with melanoma requires systemic oncologic treatment, a number of clinical trials will soon open at CHOP. These clinical trials, focusing on new drugs approved in adults with melanoma, will establish appropriate dosing and activity of targeted small molecule inhibitors and immunotherapies for children and adolescents with melanoma and other advanced cancers.Melinda Jen Melinda Jen, MD

Here are some details of what the CHOP team offers:

Multidisciplinary approach. The team includes Fox, Jen, dermatopathologist Adam Rubin, MD; general pediatric surgeon Peter Mattei, MD, for excision and lymph node biopsy when warranted; and pediatric plastic surgeon Oksana Jackson, MD, for excision for lesions of the face and other sensitive areas. They consult together on all referrals to CHOP when there is suspicion for melanoma or MelTUMP.

Consistent pathology. Rubin, who specializes in pediatric dermatopathology at the University of Pennsylvania’s Department of Dermatology and Laboratory Medicine, evaluates all pediatric skin lesions with suspicion for melanoma or MelTUMP. Currently one of the challenges in determining treatment course is varying classification by pathologists. Uniformity in classification and molecular analysis are crucial in determining treatment recommendations, such as whether lymph node biopsy is warranted, and building a database that provides accurate insight into malignant potential of skin lesions.

Structured follow-up. Children diagnosed with a melanoma or MelTUMP see Jen for skin checks every three months in the first year after diagnosis and then every six months for at least five years.

Registry. Jen began a registry of pediatric melanoma and MelTUMPs on July 1, 2014, a key step toward beginning to predict malignancy potential.

Variety of clinical trials. Just five years ago, the systemic treatment options for all patients with melanoma were limited. Since 2011, the FDA has approved five new therapies for adults with advanced melanoma. Within the next six months, clinical trials for children and adolescents will evaluate new drugs that have demonstrated benefit in adults with advanced melanoma. These include collaborations with the Children’s Oncology Group and pharmaceutical companies to study an oral MEK inhibitor, an antibody directed against Programmed Death Pathway in cancer cells (PD-1), and combination immunotherapy in children and adolescents with advanced cancer including melanoma.

Tumor predisposition expertise. In some cases, pediatric melanoma may be due to an underlying hereditary predisposition. If there is suspicion, the team is able to turn to their colleagues at CHOP and refer the patient and family for evaluation and genetic counseling in CHOP’s Pediatric Tumor Predisposition Clinic.

If you’d like more information about the pediatric melanoma and MelTUMP team at CHOP or would like to discuss a case, please call Mia Benson-Smith, MS, at 267-426-0762 or contact us online.