Author: A/Prof Patrick Emanuel, Dermatopathologist, Auckland, New Zealand; Harriet Cheng BHB, MBChB, Dermatology Department, Waikato Hospital, Hamilton, New Zealand, 2013. This can cause considerable diagnostic difficulty and be impossible to correctly recognise without clinical information. Nirmal AJ, Maliga Z, Vallius T, Quattrochi B, Chen AA, Jacobson CA, Pelletier RJ, Yapp C, Arias-Camison R, Chen YA, Lian CG, Murphy GF, Santagata S, Sorger PK. Intermediate risk melanoma: 1mm - 4mm in thickness. Presence of large epithelioid cells with abundant cytoplasm containing a round eosinophilic, Tumour cells have abundant eosinophilic or clear cytoplasm with fine granular or, Feature of vertical growth phase melanoma. Comparison of surgical margins for lentigo maligna versus melanoma in situ. Contributed by Fabiola Farci, MD, Malignant melanoma of the skin. Note that this may not provide an exact translation in all languages, Home Based on the Breslow Depth, the surgeon decides on surgical excision margins. Contributed by Fabiola Farci, MD. Melanocyte proliferation can be seen extending over the tips of the papillae in continuity from one rete ridge to another. DOI: 10.1016/j.jaad.2015.04.014. This is why such screening is an important detail to discuss. Serial sectioning and immunohistochemical studies should be performed to exclude superficial cases in some cases. Melanoma in situ (MIS) poses special challenges with regard to histopathology, treatment, and clinical management. Deep Margins: added reporting options for melanoma in situ . Those antibodies are then injected into the patient and are ready to fight cancer cells. The usefulness of this marker to discriminate pigmented actinic keratosis from early melanoma in situ, however, has not yet been a subject of investigation. Melanoma in situ: acral lesion with parallel ridge pattern (B), Melanoma in situ: before and after Imiquimod cream (A, B), Acral lentiginous melanoma, vertical growth phase, Dermal nodule with prominent pigmentation, Spindle cell melanoma with mitotic figures. These examples use aspects from the following sources: Katarzyna Lundmark, Britta Krynitz, Ismini Vassilaki, Lena Mlne, Annika Ternesten Bratel. Invasive dermal components show lack of maturation and varying degrees of atypia. Abstract. Metastatic deposits may have clinical and histological features of a blue naevus with subtle cytological atypia. The final pathology report determines the pathologic stage and helps to determine the treatment options. Melanoma in situ. Management of melanoma is evolving. In this 10x field is shown the superficial spread of atypical melanocytes invading the epidermis. Most melanomas have an initial radial growth phase within the epidermis and sometimes within the papillary dermis (figure 1, 2), which may be followed by a vertical growth phase with deeper extension (figures 3, 4). Higgins HW 2nd, Lee KC, Galan A, Leffel DJ. Thinning or consumption of the epidermis may occur. Figure 1 Protocol posting date: June 2017 . Breslow thickness is strongly correlated with melanoma survival and is a component of the clinical staging system for melanoma. Published by Elsevier Inc. All rights reserved. Figure 4. Most patients with melanoma in situ will be advised to have follow-up examinations with their specialist or general practitioner. Once surgery plans are made, the surgeon has to decide whether a sentinel lymph node biopsy needs to be performed. These tumours are often negative with immunohistochemical studies for HMB-45 and Melan-A but S100 or SOX10 can be very helpful because these are practically always positive (see figure 26). This site needs JavaScript to work properly. arrow-right-small-blue H&E stain. T3 - the melanoma is between 2.1mm and 4mm thick. If left untreated, this tumour can change over time . Less than 0.76 mm excised with 1 cm margin. Malignant melanoma, also melanoma, is an aggressive type of skin cancer that can be diagnostically challenging for pathologists. An official website of the United States government. Histopathology, treatment, and clinical management. All patients should be counseled on skin cancer preventative tactics such as staying out of the sun and wearing high sun protection factor (SPF) on exposed areas even with the cloudy weather. It becomes more distinctive in time, often growing over months to years or even decades before it is recognised. Tzellos T, Kyrgidis A, Mocellin S, Chan AW, Pilati P, Apalla Z. Cochrane Database Syst Rev. It can also appear in an existing or new mole. sharing sensitive information, make sure youre on a federal Invasive melanoma of the skin has features melanoma in situ, but also has dermal involvement of atypical melanocytes with cytologic atypia and no maturation.[6]. Melanoma most commonly metastasizes to the skin and lungs, but sometimes metastasizes to the small bowel (most common site of metastases). (WC/Nephron) Melanocytic lesions are commonly encountered in dermatopathology and an area which causes some difficulty, i.e. When there are an abundance of tumour cells the lesion may be reported as spindle-cell melanoma. Accessibility The risk factors for skin melanoma is excessive exposure to the sun, especially in people with lighter skin. Lancet Oncol. Clark level is a decrete measure indicative of the anatomical level of invasion. In this review, we assessed all available contemporary evidence on clearance margins for MIS. HHS Vulnerability Disclosure, Help Two staging systems are available to assess depth: Breslow and Clark levels. Figure 23. The relative proportion of tumour cells to surrounding stroma is variable. The .gov means its official. 2016;17(2):184192. Click Learn more about melanoma survival rates. Melan-A revealed rare positive cells in the dermis indicative of early invasion. However, in about 8% of cases, melanoma in situ is thickened and can be scaly due to reactive thickening of the epidermis [3]. Lentigo maligna and malignant melanoma in situ, lentigo maligna type. The negligible mortality and normal life expectancy associated with patients with MIS should guide treatment for this tumor. Staged excision versus Mohs micrographic surgery for lentigo maligna and lentigo maligna melanoma. Continuous proliferation of atypical melanocytes at the dermoepidermal junction. Detection and treatment of MIS is important, due to the risk of occult invasion or progression to invasive melanoma. In this case, this means complete or partial disappearance from areas of the dermis (and occasionally from the epidermis), which have been replaced by fibrosis, accompanied by melanophages, new blood vessels, and a variable degree of inflammation. Fast raster-scan optoacoustic mesoscopy enables assessment of human melanoma microvasculature in vivo. Frozen sections have no place in clinically and radiologically non-suspicious sentinel lymph nodes. T1 - the melanoma is 1mm thick or less. Genetic and Environmental Determinants of Immune Response to Cutaneous Melanoma. For LM, any MIS on the head/neck, and/or 3 cm in diameter, all may require wider clinical margins because of the higher likelihood of subclinical spread. Melanoma in situ (stage 0) Melanoma in situ is also called stage 0 melanoma. See Figures 10, 11, 12, 13, 14, 15. Angiotropism with melanoma cells around and infiltrating vessel walls or angiomatoid change with blood-filled. Dashed lines here mean that either side could be used. Dermal subtypes of melanoma include: Melanoma in situ may be suspected clinically or by dermoscopy. Patients with melanoma in situ may have also been diagnosed with other keratinocytic forms of skin cancer, such asbasal cell carcinoma,actinic keratosis,intraepidermal squamous cell carcinoma, andcutaneous squamous cell carcinoma. Melanoma in situ is treated byexcision biopsy. A technetium colloid is injected around the lesion site, and a lymphoscintigraphy scan will determine which lymphatic drainage tract is draining the lymph node. Sometimes skin grafting is required to cover the excised region if not enough skin is available for primary closure. Highly atypical melanocytes in the dermic component. Walling HW, Scupham RK, Bean AK, Ceilley RI. Copy edited by Gus Mitchell. When diffusely metastatic, there are chemotherapy options available, namely intralesional Bacillus Calmette-Guerin therapy (BCG) or immunotherapy with vaccines aimed to raisethe levels of anti-melanoma tumor antibodies. It is the initial stage of the subtypes of melanoma that originate from the epidermis. Note that this may not provide an exact translation in all languages, Home Melanocytes are cells that produce melanin - the pigment that gives skin its color A normal skin is composed of three layers: Epidermis - the outermost protective layer Dermis - the middle layer containing blood vessels, sweat glands, hair follicles, and nerves It fits into the larger category of melanocytic lesions which includes many benign entities, a number of which can be difficult to distinguish from melanoma. Figure 2 government site. They most commonly arise in superficial spreading and nodular melanomas. Dermal changes include solar elastosis and the presence of melanophages and small foci of lymphocytes. This wonderful acronym is a term used for melanocytic tumours which defy accurate classification by pathologists. FRR1 Research should identify which clinicopathological or molecular factors predict poor outcome, which might facilitate a scoring system (1-5) for risk. Ulceration, if present, is a poor prognostic factor. Clinical appearance of LM compared to non-LM melanoma in situ. Ministry of Health. The term in situ refers to a tumour which has not breeched the basement membrane. Melanoma in situ (MIS) poses special challenges with regard to histopathology, treatment, and clinical management. These tumours are most commonly found on the back in males and legs in females. Tissue microarrays (TMA) have become an important tool in high-throughput molecular profiling of tissue samples in the translational research setting. [note 5], For a full list of contributors, see article. Tumor infiltrating lymphocytes (TILs): present (nonbrisk), Margin: minimal distance to the nearest peripheral margin 4 mm, Differential diagnosis of melanoma may be very broad, Changes according to the histological subtype, Invasive melanoma may mimic any undifferentiated malignancy (. J Amer Acad Dermatol 2015: 73: 181190. Data from a number of large independent data sets supported the . Bellavia MC, Nyiranshuti L, Latoche JD, Ho KV, Fecek RJ, Taylor JL, Day KE, Nigam S, Pun M, Gallazzi F, Edinger RS, Storkus WJ, Patel RB, Anderson CJ. Copyright 2015 American Academy of Dermatology, Inc. However, as a result of the high incidence of subclinical extension of MIS, especially of the lentigo maligna (LM) subtype, wider margins will often be needed to achieve complete histologic . Vertical growth phase melanoma easily confused with a benign naevus. Lentiginous melanoma pathology Indeed, it seems that this is unlikely to be the case. 5 Melanoma Institute Australia, The University of Sydney, 40 Rocklands Road, North Sydney, NSW, 2060, Australia. Differential diagnoses for melanoma in situ include invasive melanoma, other forms of skin cancer, and benign skin lesions, such as a melanocytic naevus or lentigo(these may have been clinically described as atypical naevus oratypical solar lentigo). The 5-year survival rate as of 2018 for local melanoma, including Stage 0, is 98.4%. Wellington: Ministry of Health, 2016. Reporting regression with melanoma in situ: reappraisal of a potential paradox. Consists of two distinct populations of tumour cells: These melanomas arise as a result of a mutation in the BAP-1, LEVER'S HISTOPATHOLOGY OF THE SKIN. Treatment options in melanoma in situ: topical and radiation therapy, excision and Mohs surgery. ), Malignant melanocytic tumor arising from melanocytes, Accounts for majority of mortality due to skin cancer, Breslow depth is the most important prognostic factor, Historically called melanose and fungoid disease (, Incidence has risen rapidly over the last 50 years, Intense intermittent sun exposure (or artificial UV radiation sources), Cutaneous melanoma: anywhere on the skin's surface, including subungual location, Multistep process that involves interaction of genomic, environmental and host factors, Mitogen activated protein kinase (MAPK) pathway (RAS / RAF / MEK / ERK), Melanoma can occur de novo or develop on a pre-existent nevus, known as melanoma arising in nevus, Ultraviolet exposure is the main etiological factor, Cumulative sun damage (CSD) (pathways I - III), Low CSD (superficial spreading melanoma / L CSD nodular melanoma), High CSD (lentigo maligna melanoma / H CSD nodular melanoma / desmoplastic melanoma), Not consistently associated with cumulative sun damage (pathways IV - IX), Spitz melanoma, acral melanoma, mucosal melanoma, melanoma arising in congenital nevus, melanoma arising in blue nevus and uveal melanoma, Flat, slightly elevated, nodular, polypoid or verrucous pigmented lesion, ABCDE rule (superficial spreading melanoma, lentigo maligna melanoma, acral lentiginous melanoma), Dysplastic nevus syndrome (BK mole syndrome), Total body skin examination for the identification of clinically suspicious lesions, Histopathological diagnosis after wide surgical excision is the gold standard, Correlation with clinical parameters including age, gender, anatomical location and dermoscopic findings, High risk sites: back, upper arm, head and neck and acral sites, Absent or nonbrisk tumor infiltrating lymphocytes, Histologic subtype (pure desmoplastic melanoma and Spitz melanoma may have better prognosis) (, 21 year old woman with a cutaneous lesion arising from the scalp (, 34 year old man with a giant congenital nevus of the axilla (, 61 year old woman with productive cough and chest pain (, 67 year old Caucasian woman with a tender subungual nodule (, 67 year old man with progressive dysphagia (, 70 year old woman with shortness of breath and wheezing (, 72 year old man presented with a cutaneous lesion on the scalp (, 73 year old man presented with a rapidly growing nodule on his lower left lateral thigh (, 79 year old Caucasian woman with a persistent nodule on her posterior neck and a slowly enlarging mass on the posterior scalp (, 82 year old man with unusual histopathological presentation (, 85 year old man with a grayish nodule on the forehead (, Wide surgical excision with safety skin margins according to Breslow depth, Sentinel lymph node biopsy (staging procedure and prognostic value), Adjuvant / systemic therapy starting from stage III melanomas, Target therapy (BRAF and MEK inhibitors, KIT inhibitors), Checkpoint inhibitors (PD1 / PDL1 inhibitors, CTLA4 blockade), Skin ellipse with a lesion on the surface of variable presentation according to the clinical aspect (see, Asymmetry (assessed at scanning magnification), Pagetoid melanocytes (single scattered melanocytes, especially in the upper layers of the epidermis), Irregular distribution of junctional melanocytes, Invasion of single cells or small nests in the papillary dermis, Early vertical growth phase: dominant nest within the papillary dermis (expansile nest larger than any junctional nests), Complex and asymmetrical growth pattern (irregular nests / fascicles), Absence of maturation (lack of decreasing size of melanocytes / nests from the top to the base of the lesion), Increased dermal mitotic activity (> 1/mm), Nuclear enlargement (> 1.5 basal keratinocytes), Coarse irregular chromatin pattern with peripheral condensation ("peppered moth" nuclei) (, Variable inflammatory infiltrate (brisk, nonbrisk, absent), Asymmetrical proliferation of atypical melanocytes, Predominant junctional single units of melanocytes rather than nests, Prominent pagetoid spread (area > 0.5 mm), Elderly patients on chronic sun damaged skin, Confluent growth of solitary units of melanocytes along the dermoepidermal junction forming small nests (lentiginous pattern), Confluent horizontal arranged nests of variable size and shape (nevoid / dysplastic-like pattern), Most common in African Caribbeans and Asians, Acral location (palms, soles and subungual), Asymmetrical lentiginous proliferation > 7 mm, Melanocytes mainly at the tips of cristae profunda intermedia (, Junctional component not beyond the dermal component, Nodular dermal proliferation of atypical melanocytes, Subtle scar-like paucicelluar dermal proliferation of spindle cells, May be sarcoma-like pleomorphic spindle cell melanoma with only partial desmoplasia, Atypical lentiginous junctional melanocytic proliferation in ~50%, May be pure or mixed (associated with conventional melanoma), Mixed: more than 10% conventional or spindle cell type, Pure DM has higher local recurrence but lower regional lymph node involvement (, MelanA / MART1, tyrosinase, HMB45 negative, Long thin rete ridges due to stuffed papillae: puffy shirt sign (, Presence of a pre-existing blue nevus at the periphery, High cellular density with no intervening stroma, Great variability of cytological presentation, Epithelioid, spindle cells or giant cells, Dispersed and finely granular pigment (may be subtle or obscure other cytological details), Intracytoplasmic melanosomes and premelanosomes, Molecular alterations do not constitute proof of malignancy per se and have to be interpreted in light of the clinical and histological findings, In contrast with benign nevi, melanomas harbor multiple chromosomal copy number aberrations, Main chromosomal copy number aberrations (detected by FISH, comparative genomic hybridization [CGH], array CGH and single nucleotide polymorphism array), Main genetic driver alterations (detected by PCR, Sanger and next generation sequencing), Telomerase reverse transcriptase promoter (, Generally high tumor mutational burden (TMB > 10 mut/Mb), Gene expression profile (GEP), mRNA expression level of uveal and cutaneous melanoma related genes (, Invasive melanoma, superficial spreading melanoma subtype. MeSH Features suggesting metastasis are extensive lymphovascular invasion. Histological features of acral lentiginous melanoma include an asymmetrical proliferation of melanocytes at the dermo- epidermal junction. 2021 Mar;313(2):65-69. doi: 10.1007/s00403-020-02106-w. Epub 2020 Jul 6. It is also known as in-situ melanoma and level 1 melanoma. Which of the following stains is useful to distinguish melanoma cells from melanocytes? Mutations in DNA cause melanoma. 2019;394(10197):471477. Metastatic melanoma should be treated with surgery for palliation only and adjuvant chemotherapy and interferon therapy. Melanoma deposit in dermis or subcutis with no in-situ component possibly due to regression or derivation from non-epidermal melanocytes. Unfortunately, high-throughput profiling in small biopsy specimens or rare tumor samples (e.g., orphan diseases or unusual tumors) is often precluded due to limited amounts of tissue. Superficial spreading melanoma is the most common type of melanoma, accounting for around 70 percent of all cases. Based on the literature, a range of 5% to 29% of melanoma in situ cases are upstaged to invasive malignant melanoma after review of the pathology specimen obtained from complete excision Upstaging occurs more frequently after shave biopsy specimens In a way, they are. sharing sensitive information, make sure youre on a federal The mean age of diagnosis is 61 years, but melanoma in situ can also be diagnosed in young people [3]. Histologic evidence of partial regression is seen in 10-35% of primary cutaneous melanomas. Tis (tumor in situ) The tumor is limited to the epidermis There is no invasion of surrounding tissues, lymph nodes, or distant sites Risk: Very low Characteristics of Stage 0 Melanoma Stage 0 melanoma is a tumor limited to the epidermis. Results of a multi-institutional randomized surgical trial. Melan-A can be helpful to delineate the lesion and illustrate follicular invasion (figure 19). lentigo maligna; melanoma; melanoma in situ. The treatment for malignant melanoma is wide, local excision with margins noted above. Int J Dermatol. Hay J, Keir J, Jimenez Balcells C, Rosendahl N, Coetzer-Botha M, Wilson T, Clark S, Baade A, Becker C, Bookallil L, Clifopoulos C, Dicker T, Denby MP, Duthie D, Elliott C, Fishburn P, Foley M, Franck M, Giam I, Gordillo P, Lilleyman A, Macauley R, Maher J, McPhee E, Reid M, Shirlaw B, Siggs G, Spark R, Stretch J, van Den Heever K, van Rensburg T, Watson C, Kittler H, Rosendahl C. Australas J Dermatol. Melanoma in situ may be cured with simple excision and require a narrower excision margin than invasive melanoma (unless margins are unclear as is often the case with facial melanoma in situ). Unable to load your collection due to an error, Unable to load your delegates due to an error. A safe procedure for thin cutaneous melanoma. Interventions for melanoma in situ, including lentigo maligna. Less cellular variants may be mistaken for dermatofibroma. Lentigo maligna is a subtype of melanoma in situ that is characterized by an atypical proliferation of melanocytes within the basal epidermis; lentigo maligna that invades the dermis is termed lentigo maligna melanoma. Revised notes . Figure 4. Figure 18 Langerhans cells (LCs) constitute a cellular immune network across the epidermis. One of the problems we have as pathologists with the advent of sentinel lymph node biopsies is how to interpret collections of melanocytes in the lymph node are they bland naevus cells or small deposits of metastatic melanoma? . Puckett Y, Wilson AM, Farci F, et al. Idorn LW, Datta P, Heydenreich J, Philipsen PA, Wulf HCO. Figure 10 Figure 15. misdiagnosis of melanoma, mainly underdiagnosis, constitutes 13% of total pathology-related medical malpractice lawsuits, the second largest group of malpractice claims. While the evidence supporting this is weak, these guidelines are generally consistent. 2 recurrent problems include melanoma misdiagnosed as a melanocytic nevus (without disclosure of diagnostic doubt), chronically inflamed nevus, spitz nevus, and Typically, melanoma in situ is an irregular pigmented patch of skin. Contents 1 Fixation 2 Gross processing 2.1 Gross examination 2.2 Tissue selection 3 Microscopic evaluation 3.1 Differential diagnoses 3.1.1 Dysplastic nevus Lentigo maligna melanoma (LMM) is a subtype of melanoma, which occurs on chronic sun exposed skin of scalp, face or neck. Treatment options in melanoma in situ: topical and radiation therapy, excision and Mohs surgery. The negligible mortality and normal life expectancy associated with patients with MIS should guide treatment for this tumor. Until optimal surgical margins can be better defined in a randomized trial setting, ideally controlling for MIS subtype and including correlation with histologic excision margins, techniques such as preliminary border mapping of large, ill-defined lesions and, most importantly, sound clinical judgement will be needed when planning surgical clearance margins for the treatment of MIS. In the past, physicians used the Clark level. Metastatic melanoma pathology Histologic appearance of LM compared to non-LM melanoma in situ. Melanoma in situ - patholines.org Melanoma in situ Author: Mikael Hggstrm [note 1] Melanoma of the skin generally presents as a dark skin focality and/or a suspected malignant skin excision . Fair-skinned and light-haired persons living in high sun-exposure environments are at greatest risk. Figure 7 Careers. [[Locations are mainly the deep edge, or the (superior/inferior/medial/lateral) radial edge.]]." Dermoscopy revealed an asymetric pattern with blue-gray globules and focal structureless areas. 2015 Aug;73(2):181-90, quiz 191-2. doi: 10.1016/j.jaad.2015.04.014. The pathological diagnosis of melanoma can be very difficult. The most common subtypes are: Lentigo maligna Lentiginous melanoma in situ Superficial spreading melanoma in situ. In general terms, melanoma in situ is macular (flat). . Genetic testing is available to determine who is at high risk of recurrence or in patients with a family history of melanoma or pancreatic cancer. Clinical appearance of LM compared to non-LM melanoma in situ. doi: 10.1002/14651858.CD010308.pub2. Breslow thickness is not reported for melanoma in situ. Usually, a lymphoscintigraphy scan is performed on the day of surgery. Patients with melanoma in situ have the same life expectancy as the general population. 2015 May;95(5):516-24. doi: 10.2340/00015555-2035. DermNet does not provide an online consultation service.If you have any concerns with your skin or its treatment, see a dermatologist for advice. Figure 21 Epidemiology, screening, and clinical features. If a melanoma is found, the pathology report will provide information that will help to plan the next step in treatment. Superficial spreading melanoma pathology Community-based programs designed to screen individuals at risk aid in early diagnosis and may ultimately improve mortality associated with malignant skin neoplasia. Part I. doi: 10.1016/S1470-2045(15)00482-9. The negligible mortality and normal life expectancy associated with patients with MIS should guide treatment for this tumor. Because they are located at the skin barrier, they are considered immune sentinels of the skin. Indicators of poor prognosis in melanoma are listed in the table below. Many pathologists still report the Clark level to avoid unnecessary telephone conversations. However, the issue is your risk of this skin growth causing health problems. Fair-skinned and light-haired persons living in high sun-exposure environments are at greatest risk. Arch Dermatol Res. New Zealand has the highest rate of melanoma worldwide and risk is greatest for non-Mori men aged over 50 years. Some in-situ melanomas develop foci (a centre of a morbid process) or a more potentially dangerous, invasive form of melanoma. doi: 10.1001/archsurg.1991.01410280036004. The understanding of pathology of melanoma has evolved over the years, with the initial classifications based on the clinical and microscopic features to the current use of immunohistochemistry and genetic sequencing. Figure 9 shows the Melan-A stain for a case of what was thought to be a melanoma in situ on routine sections. Specifically, the ABCDEs should be assessed: asymmetry, border irregularity, color (variation), diameter (more than 5 mm), and/orerythema. Neurotropic melanoma describes a variant of desmoplastic melanoma where there is infiltration of nerves and tumour cells can be seen arranged in a concentric fashion around nerve fibres. Most international clinical guidelines recommend 5-10 mm clinical margins for excision of melanoma in situ (MIS). In 5-15% of cases of metastatic melanoma, the primary tumor is never found, presumably due to complete regression. Lentigo maligna is the precursor lesion and is a form of melanoma in-situ. Bottom image shows which side of the slice that should be put to microtomy. Depending on the depth of the lesion, the 10-year survival rate varies tremendously. However, Breslow level is now the standard of care because it is more specific. The available data challenge the adequacy of current international guidelines as they consistently demonstrate the need for clinical margins > 5 mm and often > 10 mm. Usually the lack of epidermal involvement is a good clue the tumour is a metastasis from another site but sometimes the metastasis may invade the epidermis and closely simulate a primary melanoma. Lymphocytes are immune cells. Melanoma pathology: Normal FISH Epub 2022 Apr 19. This page was last edited on 19 June 2022, at 15:48. Ulceration: Ulceration is a breakdown of the skin over the melanoma.