Choroidal melanoma

1) Disease Description (Causes and Symptoms)

• Definition: Malignant melanoma is a malignant neoplasm of the skin (or mucous membranes) that arises from melanocytes, the cells that produce melanin.
• Causes/Pathophysiology:
  • Multiple risk factors are involved, and there is no single precisely identified cause.
  • In White people, ultraviolet (UV) exposure and genetic predisposition are known to be important risk factors. In contrast, among Asian people, melanoma of acral sites such as the soles, fingernails and toenails, and palms (acral lentiginous melanoma) is common, and its association with UV exposure is relatively limited.
  • Tumor invasion depth (Breslow depth), surface ulceration, and mitotic rate determine the risk of progression and metastasis.
• Main Symptoms (Clinical Clues):
  • Changes in the shape or color of an existing mole, or a new black-colored lump (asymmetry, irregular borders, color variation, diameter >6 mm, enlargement, etc. — applying the ABCDE criteria)
  • Itching, bleeding, and ulceration may occur
  • Acral melanoma may begin as a black line or discoloration on the sole or fingernail/toenail

2) Treatment Methods

• Diagnostic principle: Suspicious lesions are confirmed by biopsy at a dermatology department (diagnostic excisional biopsy or partial biopsy).
• Surgery:
  • Complete excision of a localized lesion (removing surrounding normal skin together with an adequate margin). The width of excision is determined according to the stage (tumor thickness).
  • If the degree of invasion exceeds a certain level, sentinel lymph node biopsy (or regional lymph node dissection) is recommended to evaluate for metastasis and help determine the stage.
• Systemic Treatment (Advanced/Metastatic):
  • Immune checkpoint inhibitors (immunotherapy): PD-1 inhibitors (e.g., pembrolizumab, nivolumab) alone or in combination with a CTLA-4 inhibitor (ipilimumab) — standard treatment for metastatic disease and some adjuvant treatment settings.
  • Targeted therapy: In patients positive for the BRAF V600 mutation, combination treatment with a BRAF inhibitor and a MEK inhibitor (e.g., dabrafenib + trametinib, etc.) is effective.
  • Conventional interferon or chemotherapy (such as dacarbazine) has a limited role compared with modern standard treatments.
• Radiation Therapy:
  • Used for local symptom relief or in some sites (such as brain metastases).
• Adjuvant Therapy (After Excision):
  • Depending on the stage and molecular phenotype, adjuvant immunotherapy or targeted therapy may be considered.
• Lifestyle Management and Precautions:
  • Wound care after surgery and management of lymphedema if lymph nodes are removed
  • During immunotherapy, monitor for immune-related adverse reactions (skin rash, colitis, liver function abnormalities, endocrine disorders, etc.) and report them immediately

3) Checkpoints Before an Outpatient Visit (Including Items to Bring and Example Questions)

• Items to Bring (Bringing these can make the consultation easier):
  • A list of medications currently being taken (prescription drugs, nonprescription drugs, herbal medicines, and supplements)
  • Past medical history (especially skin cancer and a family history of melanoma), as well as records of surgeries and allergies
  • Previous test results (biopsy reports, pathology findings, and imaging interpretation reports)
  • Recent photographs of the lesion (from multiple angles, along with older photographs for comparison of size)
  • A record of when symptoms began and how they have changed (size, color, bleeding, itching, etc.)
• Possible Blood Tests and Examinations During the Outpatient Visit:
  • Visual examination of the skin lesion and, if necessary, full-thickness excisional biopsy or partial biopsy
  • If staging is suspected, chest and abdominal CT, bone scan, PET-CT, or MRI (especially if brain metastasis is suspected), according to the biopsy results
  • Molecular testing (BRAF/NRAS/CKIT, etc.) — important for planning systemic treatment
• Example Questions (Questions to organize in advance before the consultation):
  • Is it certain that the lesion currently visible is malignant melanoma?
  • When and how can the biopsy be performed?

4) Examples of General Questions to Ask the Doctor

• “What does my pathology result (or biopsy result) mean? What is the stage?”
• “Which treatment options (surgery, immunotherapy, targeted therapy, etc.) are recommended in my case? What are the expected benefits and side effects of each?”
• “What should I be careful about in daily life to reduce the risk of recurrence or metastasis after treatment?”
• “What side effects may occur during treatment, and how should I contact you if a problem arises?”

5) Examples of Disease-Specific Questions

• “How do the Breslow depth and presence or absence of ulceration stated in the pathology report affect my prognosis and treatment decisions?”
• “Do I need testing for BRAF gene mutations? Depending on the test results, which medications (targeted therapies) can be used?”

(Note: In Asia/Korea, melanoma of the soles and fingernails/toenails is relatively common, and because these acral forms have a limited association with UV exposure, early suspicion and biopsy are especially important.)