Clinical Practice Guideline

for

MELANOMA

Developed for the

Aerospace Medical Association

by their constituent organization

American Society of Aerospace Medicine Specialists

 

Overview: The incidence of malignant melanoma in the U.S. was approximately 12.5 per 100,000 persons in 1996, and is increasing at a faster rate than any other cancer. For diagnosis, obtain a dermatology consultation, perform an excisional biopsy on all suspicious lesions, and submit specimens to pathology. Predominant risk factors associated with a poorer prognosis include greater tumor thickness, tumor ulceration, primary tumor located axially or on palms/soles, higher stage of disease, and nodal or distant metastasis. Airman must be removed from flying duties while undergoing therapy. Wide and deep excision remains the definitive treatment for malignant melanoma.

 

Aeromedical Concerns: The ultimate concern is the risk of an in-flight incapacitating event. Recurrence rates within two years after surgical treatment of American Joint Committee on Cancer (AJCC) stage I and II melanoma can be as low as 2% for minimal stage I disease, and up to 70% or more for thicker stage II tumors. Of those with recurrent disease, approximately 20% will present with metastasis to the brain. Approximately 57% of brain metastases from melanoma have led to a seizure, or other incapacitating neurological event, as the presenting symptom. The overwhelming majority of specialists queried support the view that MRI is a reasonable and reliable technique that can detect CNS lesions before they become clinically apparent, thereby protecting aviation safety while permitting medical certification of airmen with certain malignancies. The waiver decision table and guidelines listed below take these percentages into account, along with the latest statistical data from the largest melanoma study group to date. The calculations used to design these guidelines are based on a one-percent annual risk of sudden incapacitation as a limiting rate. Other factors that must be considered prior to granting a waiver include surgical wounds, scars, and skin graft sites affecting range of motion, and proper/comfortable fit of flying equipment. Typical down days during treatment and waiver decision process for melanoma range from several months to permanently, depending on stage of disease, lesion size, location, extent of surgery, and recovery.

 

Waiver Decision Guidelines in the USAF:

 

AJCC Stage I and II (Clinically Localized Melanoma: pT1-4, N0, M0)

Breslow Thickness (mm)

Tumor Ulceration

Lesion Location

Aeromedical Disposition

 

 

 

 

<0.76

Yes or No

Any Site

UW*

 

 

 

 

0.761.49

No

Any Site

UW*

 

Yes

Extremity (except Palms & Soles)

DQ (Min 2 yrs)

 

Yes

Axial or Palms or Soles

DQ (Min 5 yrs)

 

 

 

 

1.502.49

No

Extremity (except Palms & Soles)

UW*

 

No

Axial or Palms or Soles

DQ (Min 2 yrs)

 

Yes

Extremity (except Palms & Soles)

DQ (Min 2 yrs)

 

Yes

Axial or Palms or Soles

DQ (Min 5 yrs)

 

 

 

 

2.503.99

No

Extremity (except Palms & Soles)

DQ (Min 2 yrs)

 

No

Axial or Palms or Soles

DQ (Min 2 yrs)

 

Yes

Extremity (except Palms & Soles)

DQ (Min 2 yrs)

 

Yes

Axial or Palms or Soles

DQ (Min 5 yrs)

 

 

 

 

> or = 4.00

Yes or No

Any Site

DQ (Min 5 yrs)

AJCC Stage III Melanoma (any pT, N1/N2, M0)

Any Stage III Disease = DQ (Min 5 yrs)

 

AJCC Stage IV Melanoma (any pT, any N, M1)

Waiver is not recommended for any Stage IV disease

* UW = Unrestricted Waiver. All waivered cases require close follow-up for life, at intervals

recommended by the evaluating dermatologist/oncologist.

DQ (Min 2 yrs) = Disqualified for two years, beginning after treatment is completed. If disease-free and fully mission capable after this period, as determined by a flight surgeon evaluation and a mandatory dermatology evaluation (and oncology evaluation if indicated), then recommend unrestricted waiver. All waivered cases require close follow-up for life, at intervals recommended by the evaluating dermatologist or oncologist.

DQ (Min 5 yrs) = Disqualified for five years, beginning after treatment is completed. If disease-free and fully mission capable after this period, as determined by a flight surgeon evaluation and a mandatory dermatology evaluation (and oncology evaluation if indicated), then recommend unrestricted waiver. All waivered cases require close follow-up for life, at intervals recommended by the evaluating dermatologist or oncologist.

 

Medical Work-up: In order to make an intelligent aeromedical disposition, the following are needed: Full dermatological consultation (and oncology/surgery consultation if indicated), with a copy(s) of report(s) attached, which specifically rule-out metastatic disease; a copy of the pathology report, specifically indicating histologic diagnosis of melanoma, presence or absence of tumor ulceration, and Breslow depth; confirmation of histology, ulceration, and Breslow depth, with a copy of report attached; copies of all laboratory studies, radiological studies, and any other studies.

 

Aeromedical Disposition (military): This is a problematic diagnosis for the aeromedical practitioner. For the aviator with a lesion less than 0.85 mm and negative nodes, the risk for flying is probably minimal. If the lesion is thicker than 0.85 mm and/or there are positive nodes, there is an increased risk of recurrence and all factors need to be carefully weighed prior to making an aeromedical disposition.

 

Aeromedical Disposition (civilian): For civilian airmen, if there is a melanoma that is less than Breslow 0.75-mm depth, the airman is required to provide a yearly current status for a minimum of 5 yr. The consultants that were queried to come up with an overall policy for the FAA felt that Breslow depth and local lymph node metastasis were separate in their likelihood of resulting in brain lesion than distal node or other organ spread. Thus, all classes of airmen with a Breslow depth greater that 0.75 mm or local lymph node spread are required to have frequent MRI of the brain as well as a current status of their medical condition. In the case of first and second class airmen this will be every 6 months and every 12 months for third class. If there is distant lymph node spread or metastasis to other systems excluding the brain, the airman will be disqualified for 3 years and when they return for reconsideration they will be required to provide a current status and MRI of the brain every 3 months for 5 yr. For those airmen with brain metastasis, there will be a 5 year grounding period followed by the every 3 month current status and brain MRI.

 

Waiver Experience (military): In the military services a local dermatologist (and oncologist/surgeon when indicated) may perform initial evaluations. The aviator will require life-long local follow-up as described above.

 

Waiver Experience (civilian): The present pathology coding system at the Federal Aviation Administration does not have a unique code for melanoma.

 

References:

 

Balch CM, et al. An Analysis of Prognostic Factors in 8500 Patients with Cutaneous Melanoma. In Balch CM, et al (eds). Cutaneous Melanoma, 2nd Ed., New York, J.B. Lippincott Company, 1992:165-87.

 

Balch, CM, et al. Cutaneous Melanoma. In DeVita VT, et al (eds). Cancer, Principles and Practice of Oncology, 4th Ed. Philadelphia, J.B. Lippincott Company, 1993:1612-61.

 

Rayman, RB, Clinical Aviation Medicine, 3rd edition, Castle Connolly Graduate Medical Publishing, LLC, 2000, pp. 315-17.

 

Rigel DS, Rogers GS, Friedman RJ. Prognosis of Malignant Melanoma. Derm Clin 1985; 3:309-14.

 

Sampson JH, et al: Demographics, prognosis, and therapy in 702 patients with brain metastases from malignant melanoma. J Neurosurg, 1998; 88:11-20.

 

Soong S-J, et al: Predicting Survival and Recurrence in Localized Melanoma: A Multivariate Approach. World J Surg 1992; 16:191-5.

 

 

July 9, 2002