What are Melanotic (pigmented) lesions?

From the Guidelines

MELTUMP lesions, or Melanocytic Tumors of Uncertain Malignant Potential, are challenging skin lesions that require complete surgical excision with appropriate margins, followed by close clinical monitoring with regular skin examinations every 3-6 months for at least 2-3 years, as recommended by the most recent guidelines 1.

Key Characteristics of MELTUMP Lesions

• Atypical features that make it difficult for pathologists to definitively classify them as either benign or malignant
• Concerning histological characteristics such as asymmetry, irregular borders, cytological atypia, and occasional deep mitoses
• Lack the full criteria needed for a definitive melanoma diagnosis

Management of MELTUMP Lesions

• Complete surgical excision with appropriate margins
• Close clinical monitoring with regular skin examinations every 3-6 months for at least 2-3 years
• Dermatoscopic imaging and photography may be used to track any changes

Importance of Vigilant Follow-up

• The uncertainty surrounding these lesions stems from their unpredictable biological behavior
• While most behave benignly, some may progress to invasive melanoma or metastasize
• Patients diagnosed with MELTUMPs should understand this uncertainty and the importance of vigilant follow-up to detect any potential progression early, as emphasized in the latest guidelines 1.

Diagnostic Approach

• Diagnosis should be based on a full-thickness excisional biopsy with a small side margin, as recommended by the ESMO guidelines 1
• The histology report should include at least information on the type of melanoma, actinic damage, maximum vertical thickness in millimeters, information on mitotic rate in case of pT1, presence of ulceration, presence and extent of regression and clearance of the surgical margins, as outlined in the ESMO guidelines 1

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Melanoma Lesions

• Melanoma is one of the most malignant skin tumors with constantly rising incidence worldwide, especially in fair-skinned populations 2
• The clinical presentation of melanomas varies depending on the anatomic localization and the type of growth, i.e., the histopathological type of the cancer 2
• There are four major histopathological types of melanoma: superficial spreading melanoma, nodular melanoma, lentigo maligna melanoma, and acral lentiginous melanoma 2

Diagnosis and Treatment

• Dermatoscopy is a very useful tool in early melanoma detection, but dermatoscopical features of melanomas are also variable 2
• Total body photography (TBP) has been widely incorporated in clinical practice, especially for follow-up of high-risk individuals with multiple naevi 3
• Adjuvant treatment is associated with a higher recurrence-free survival (RFS) than placebo, with nivolumab/ipilimumab and dabrafenib/trametinib showing the highest RFS benefit 4
• The presence of a BRAF mutation is associated with higher RFS rates, and BRAF/MEK inhibitors should be preferred in the adjuvant treatment of BRAF-mutant non-ulcerated melanoma 4

Predictors of Malignancy

• The main predictors of malignancy in melanocytic lesions are regression structures, hypo/amelanotic color, irregular pigmentation, asymmetrical peripheral dots/globules, and asymmetry in pattern and/or color 3
• Blue-whitish veil, atypical vascular pattern, and shiny white lines are exclusively found in melanomas 3
• Melanomas presenting as new lesions are frequently featureless or feature poor on dermoscopy and difficult-to-diagnose on histopathology 3