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
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* |
|
|
|
|
|
|
0.76—1.49 |
No |
Any
Site |
UW* |
|
|
Yes |
Extremity
(except Palms & Soles) |
DQ
(Min 2 yrs)† |
|
|
Yes |
Axial
or Palms or Soles |
DQ
(Min 5 yrs)‡ |
|
|
|
|
|
|
1.50—2.49 |
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)‡ |
|
|
|
|
|
|
2.50—3.99 |
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