Malignant melanoma is rare in children, representing 1% to 3% of all pediatric malignancies. Thirty-three children with malignant melanoma were treated at St Jude Children's Research Hospital from 1967 to 1988. Their ages ranged from 1 day to 20 years (median, 12 years); 23 were boys and 10 were girls; and 5 of the 33 (15%) were black. Four of the 33 children had been treated for a previous malignancy. In 3, melanoma arose within a bathing trunk nevus. The extremity was the most common site (13), followed by the trunk (9), head and neck (7), and perineum (1). In 3 patients the primary site could not be determined. Upon initial presentation to St Jude Hospital, 17 patients had localized disease (stage I), 10 had regional node involvement (stage II), and the remaining 6 patients had disseminated disease (stage III). Using both Clark's level and Breslow's thickness as indicators, the incidence, initial stage, prognosis, and survival were compared. By Clark's level, 7 patients, (6 of whom were stage I) were level II or III, and 22 patients were level IV or V. Though 16 of 22 level IV and V patients were initially stage I, 10 patients eventually developed progressive disease. Similar observations were noted when using Breslow's thickness to evaluate the primary. In 5 of 27 evaluable patients, Breslow's depth of invasion was less than 1.5 mm. All 5 of these patients were diagnosed with stage I disease and have not shown progressive disease. Of the remaining 22 patients whose Breslow's thickness was more than 1.5 mm, 7 continue to be stage I. In the remaining 15 patients, 7 showed stage II disease. Eight other stage I patients have shown progressive disease. While initial surgery was uniformly a wide local excision, the management of nodal disease was individualized. Combination chemotherapy was administered to 19 patients (18 with measurable disease stage II-III or relapse). Three stage II patients had complete responses. In the other 15 patients, responses were variable. Twelve patients died at a median of 9 months (range, 4 to 14 months) following surgery. Twenty-one patients are alive 8 months to 21 years (median, 90 months) following surgery. In conclusion, our review shows that (1) the majority of malignant melanomas in children arise from preexisting nevi; (2) both Clark's level and Breslow's thickness are predictors of stage and eventual survival; (3) the vast majority of intermediate/thick melanomas either present as stage II or will progress; (4) chemotherapy responses, complete or partial, were noted in 8 of 18 (44%); and (5) surgery remains the mainstay of treatment. © 1990.
