Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Cancer, Skin (Melanoma)


Related Terms

  • Malignant Melanoma
  • Melanoma

Differential Diagnosis

  • Atypical mole
  • Basal cell carcinoma
  • Dermatofibromas
  • Hemangioma
  • Hematoma
  • Lentigo maligna (atypical lentiginous hyperplasia)
  • Nevus melanoma
  • Pyogenic granulomas
  • Seborrheic keratosis
  • Squamous cell carcinoma

Specialists

  • Dermatologist
  • Dermatopathologist
  • General Surgeon
  • Plastic Surgeon
  • Radiology Oncologist

Comorbid Conditions

  • Immune system disorders

Factors Influencing Duration

Duration will be affected by the stage of the disease, the individual's response to and the side effects of treatment, and metastatic complications.

Medical Codes

ICD-9-CM:
172.0 - Malignant Melanoma of Lip
172.1 - Malignant Melanoma of Eyelid, Including Canthus
172.2 - Malignant Melanoma of Ear and External Auditory Canal; Auricle (Ear); Auricular Canal, External; External [Acoustic] Meatus; Pinna
172.3 - Malignant Melanoma of Other and Unspecified Parts of Face, Cheek (External), Chin, Eyebrow, Forehead, Nose (External), Temple
172.4 - Malignant Melanoma of Scalp and Neck
172.5 - Malignant Melanoma of Trunk, except Scrotum; Axilla, Breast, Buttock Groin, Perianal Skin, Perineum, Umbilicus
172.6 - Malignant Melanoma of Upper Limb, Including Shoulder; Arm, Finger, Forearm, Hand
172.7 - Malignant Melanoma of Lower Limb, Including Hip; Ankle, Foot, Heel, Knee, Leg, Popliteal Area, Thigh, Toe
172.8 - Malignant Melanoma of Other Specified Sites of Skin
172.9 - Melanoma of Skin, Site Unspecified

Overview

Melanoma is the least common of the skin cancers but the most lethal. This cancer, which accounts for 4% of all malignant skin tumors, originates in pigment-producing skin cells called melanocytes (Swetter). These cells produce a dark pigment (melanin) responsible for skin color and tanning. Melanoma may arise from apparently normal skin or originate from an existing mole. The types of melanoma are defined by their size, color, border shape, level of ulceration, and texture. They include superficial spreading melanoma (the most common, making up about 60% of cases), nodular melanoma (10% to 15% of cases), acral lentiginous melanoma (5% to 10% of total cases, but much more common in dark-skinned individuals), and lentigo maligna melanoma (5% to 10% of cases) (Swetter, Wells). Amelanotic malignant melanoma (less than 5% of cases) is a difficult to diagnose subtype of melanoma with little or no pigment on visual inspection.

Melanoma is believed to be a multi-step process (melanomagenesis) of genetic mutations that increase cell proliferation, differentiation, and death. The process seems to increase an individual's susceptibility to ultraviolet radiation, especially in sun-exposed skin. Although some debate remains, it is difficult to deny the relationship between sunlight exposure and melanoma—typically a history of acute episodes of severe sunburns rather than the cumulative radiation, and exposure during childhood, before age five. The two types of ultraviolet light that mutate skin DNA resulting in melanoma are UVB and UVA. Although it was once thought that only the UVB sunlight was responsible for melanoma, it is now accepted that the UVA light, found not only in sunlight but also in tanning beds, is a serious threat.

For all skin cancers, prevention is the best defense. Individuals should avoid excessive sunlight exposure when possible and avoid sunburns by wearing sunscreen and protective clothing, avoid tanning beds, and be vigilant about checking their skin for changes.

Typically melanoma is first noticed in the head and neck in men, the legs in women, or the back in either sex, especially in those with a history of excessive exposure to sunlight. Melanoma also may originate in other areas that are less predictable: between the toes, under a nail (subungual melanoma), on the palms, or on the soles of the feet. In even more unusual instances, the neoplasm may occur in the moist lining of the nose, mouth, esophagus, anus, urinary tract, or vagina (mucosal melanoma). Ocular melanomas develop in the conjunctiva lining the eyelids or in a layer called the choroid within the globe of the eye.

Measuring the depth of a melanoma is critical in determining its likely outcome. As the melanoma penetrates the deeper layers of tissue, it makes contact with an increasing number of blood capillaries and lymphatic vessels, allowing transport of malignant cells to distant sites (metastasis). Once metastasized, local lymph nodes and ultimately other organs and tissues may be infiltrated. These sites may include the liver, bones, lungs, heart, kidneys, pancreas, adrenals, gastrointestinal tract, remote skin areas, and the central nervous system.

The staging of malignant melanoma depends on the lesion's thickness, the amount of ulceration, whether it has spread to regional lymph nodes, the number of lymph nodes affected, and the progression to other organs. Various staging systems use slightly different criteria to guide the oncologist's treatment choices, but with each staging system, successive stages indicate a greater degree of invasion beyond the primary site and a poorer prognosis. Breslow's classification stages tumors in four groups based on its thickness in millimeters in the excisional biopsy study: <1 mm, 1-2 mm, 2.1-4 mm, and >4 mm. Clark's staging system classifies the degree of invasion of tumors: level I is melanoma confined to the epidermis (melanoma in situ); level II is invasion to the basal layer of the epidermis; level III is invasion to the papillary dermis; level IV is invasion to the reticular dermis; and level V is invasion to the subcutaneous fat. The tumor/node/metastasis (TNM) system summarized stages are as follows: stage 0 is melanoma in situ and refers to early lesions that are shallow and have not spread; stage I is localized, less than 1.5 mm thick, and has a favorable prognosis; stage II is 1.5 mm to 4 mm thick, and although it has not spread to the lymph nodes, it has infiltrated deep into the dermis (the skin layer containing the metastatic highway), the lymphatic system and blood vessels; stage III tumors are thicker than 4 mm (¼ inch) and have spread into nearby lymph nodes; and stage IV melanoma has metastasized to distant organs through the lymph system and bloodstream, with possible metastasis to the brain, bone, and other internal organs.

Incidence and Prevalence: The incidence of melanoma increased significantly through the twentieth century but has remained steady since 2000. It is the sixth most common cancer diagnosed in the US (Swetter). Each year, about 60,000 new cases of invasive melanoma are diagnosed, resulting in about 8,400 deaths (Wells); another 54,000 cases of noninvasive melanoma confined within the lesion (melanoma in situ) are diagnosed (Swetter). Prevalence is reported to be 6.4 cases per 100,000 men compared to 11.7 cases per 100,000 women (Swetter). Estimates issued by the American Cancer Society for 2010 included 68,130 cases of melanoma, with 8,700 deaths ("Detailed Guide").

Worldwide incidence among white populations is increasing, with highest incidence reported in Australia and New Zealand; prevalence in Australia and New Zealand in 2002 was estimated to be 37.7 cases per 100,000 men and 29.4 cases per 100,000 women (Swetter).

Source: Medical Disability Advisor



Causation and Known Risk Factors

The risk of melanoma is greater for those who have had excessive sun exposure or experienced serious sunburn at an early age, as well as individuals with fair complexions and those who live in sunny climate or at high altitude. A genetic component also exists that may predispose certain individuals to greater risk of UV sensitivity. The risk increases for individuals with a first-degree relative who has had melanoma (familial atypical mole-malignant melanoma syndrome or FAMMM); those who have xeroderma pigmentosum, a genetic disorder that causes photosensitivity; and in those with a weakened immune system who are less able to repair skin damage. Moles are probably the most apparent risk factor. About 40% to 50% of melanomas arise from pigmented moles (Wells). One poorly defined (dysplastic) mole doubles the risk of melanoma (Mayo Clinic Staff). Even ordinary moles with a normal appearance elevate the risk when they occur in large numbers. Exposure to toxins such as coal tar, arsenic, pesticides, radium, and the wood preservative creosote also may increase the risk for melanoma (Mayo Clinic Staff).

Melanoma is most commonly diagnosed in those between 50 and 70 years of age, with a median age at diagnosis of 53 (Swetter). However, it is the most common cancer diagnosed in women in their late 20s and second to breast cancer in women in their early 30s (Swetter). Although women are affected slightly more than men (worldwide male/female ratio 0.97:1.0), men are at greater risk than women when over age 40 (Swetter).

Melanoma is a disease primarily of whites, typically occurring in light-skinned, blue-eyed, blond, or red-haired individuals of Scandinavian or Celtic extraction. It is rare in blacks, but when it does occur, it usually appears on the light-complected areas of the hands, feet, or mucous membranes.

Source: Medical Disability Advisor



Diagnosis

History: Typically, the individual will report a change in the character or size of a mole, or observe a suspicious new growth. Changes in a mole may include scaliness, itching, textural changes such as hardness or lumpiness, spread of pigment into surrounding area, oozing or bleeding. Usually the patient is fair-skinned, has had episodes of sunburn at an early age, or has had repeated exposure to sunlight. In other cases, a close relative may have had melanoma, or the individual may be immunocompromised either through disease such as AIDS or having received immunosuppressants as treatment for autoimmune disease or a prior cancer. If the melanoma has metastasized to other organ systems, symptoms may reflect the extent of the damage and organs affected.

Physical exam: The physical characteristics that distinguish moles from melanomas may not be readily apparent. The dermatologist follows the ABCDE guidelines for clues: (A) asymmetrical growth; (B) borders notched or scalloped; (C) colors not consistent throughout the growth; (D) diameter greater than 6 mm (¼ inch) and/or (E) elevation. The melanoma may present in a variety of shapes and colors: raised or flat; brown with black spots; raised with white, black or blue spots; or simply as black or gray lumps. Recent enlargement, darkening, bleeding, or ulceration may indicate deeper invasion of the skin.

A comprehensive physical exam will be conducted, giving special attention to those areas potentially affected by malignant melanoma: the eyes are evaluated for ocular melanoma; the consistency and tenderness of superficial lymph nodes are documented; breath sounds may give clues to pulmonary metastasis; and abdominal palpation may reveal evidence of intraperitoneal metastasis.

Tests: The definitive test for melanoma is a biopsy of the lesion at its full depth and slightly beyond its edges. The surgeon usually will remove (excise) small tumors completely and avoid disfiguring the surrounding skin. If the biopsy is negative (no cancerous cells found), that will end the procedure. If the biopsy is positive, histologic examination of the lesion tissue always precedes excision of larger lesions, and more tests will be done to assess for metastases.

The physician may order additional tests to gauge the level of possible metastasis and to evaluate related problems, including chest x-rays, blood tests such as liver function tests, and various imaging studies such as magnetic resonance imaging (MRI), computed tomography (CT) scan, and positron emission tomography (PET) scans, although the latter have a low yield of meaningful information in melanoma stages I and II. Special areas of interest if metastatic disease is present (stages III and IV) are the liver, bones, and brain. Immunohistochemical staining of tumor cells may help identify and differentiate the proliferating cell according to antigens present on the cell surfaces and fundamental changes in the cellular DNA. The reverse transcriptase–polymerase chain reaction (RT-PCR) assay identifies genetic alterations that reveal melanoma cells in the lymph nodes. This test confirms metastasis, allows appropriate treatment, and suggests the likelihood of recurrence. Other blood tests look for protein markers that point to the extent the melanoma has spread and may offer clues for treatment and prognosis.

The physician may order sentinel lymph node mapping (SLNM) to determine the route of lymphatic drainage. A sentinel lymph node is the one most likely to be affected if the melanoma should spread. Mapping is performed by injecting a dye and a radioactive tracing agent into the tumor and following its course through the lymphatic system to the first lymph node it reaches. Lymph node mapping reaches a high degree of certainty when assisted by a nuclear medicine scan (lymphoscintigraphy). A sentinel lymph node biopsy (SLNB) is then taken to help with staging. If the biopsy is negative, there is a reasonable assurance that other local lymph nodes are cancer-free.

Source: Medical Disability Advisor



Treatment

Once malignant melanoma is diagnosed, the pathologist will stage the cancer to determine its level of penetration and potential for damage. After the condition is staged, appropriate treatment begins.

At earlier stages, surgical excision of the tumor is the fundamental treatment. Initially, the surgeon excises the tumor, including some of the normal tissue surrounding it, and may remove targeted lymph nodes. Regional chemotherapy may be used in conjunction with surgery to destroy any remaining malignant cells. Treatment also may include radiation therapy and biologic therapy (substances used to boost immunity) or may combine anticancer drugs with biologic therapy. High-risk melanoma, which has a high rate (40% to 80%) of relapse and death, may be treated with adjuvant interferon alfa-2b (Intron A). Because of the poor prognosis and the lack of survival benefit shown with interferon, chemotherapy, or radiation therapy, patients with metastases may be encouraged to enroll in a clinical trial for access to experimental treatments. Although removing disseminated cancers will not produce a cure, it may reduce symptoms and improve the patient's quality of life.

Source: Medical Disability Advisor



Prognosis

The prognosis depends on the stage at which the melanoma is diagnosed and treated. The depth of the initial lesion, not its diameter, best predict prognosis. In general, the more the cancer has spread from its original site, the graver the outcome. Based in Breslow’s depth classification, the prognosis for 5 year survival is as follows: <1 mm, 95-100%; 1-2 mm, 80-96%; 2.1-4 mm, 60-75%; and >4 mm, 50%. The best prognosis is for those lesions that are discovered early, are shallow, and have not spread (melanoma in situ). These have a 5-year cure rate of almost 100% by surgical removal (Wells). The outcome is less certain and the prognosis is less favorable with each successive increase in stage. Melanoma progresses rapidly and can result in death within months of diagnosis. The 5-year survival rate for stage III melanoma ranges from 25% to 70%. Stage IV melanoma carries the poorest prognosis and has a 5-year survival rate of only about 10% (Wells). The cancer probably cannot be eliminated because of metastasis to the brain, bone, and other internal organs. Spontaneous regressions of metastasized melanoma, although rare, have been observed.

Malignant melanoma is responsible for about 74% of skin cancer deaths in the US (Swetter). Those who have early-stage cutaneous (skin) melanoma have higher 5-year survival rates (91% in the US) (Swetter). Increased education about skin care is believed to result in earlier diagnosis and treatment with greater potential for cure.

Source: Medical Disability Advisor



Complications

The primary complications of melanoma result from its metastasis to other organs and the compromised organ function that follows. Penetrating spread to deep tissues may incur physical and functional damage. Treatment using radiation, chemotherapy, or immunotherapy may result in hair loss, nausea, pain, and fatigue.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Work restrictions will be consistent with the stage of the disease, side effects of therapy, and organs affected. Time away from work may be required to pursue treatment. The side effects of treatment, including nausea, weakness, and fatigue, may compromise the worker's ability to function normally and may require worksite accommodations. As the disease progresses, tissue and organ damage will require further work restrictions.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Did individual report a mole or change in a mole with symptoms that were consistent with melanoma?
  • Does individual have an asymmetrical growth with borders that are notched or scalloped and colors that are not consistent throughout the growth?
  • Was a biopsy of the lesion done? Biopsy of nearby lymph nodes?
  • Is the growth greater than 6 mm in diameter?
  • Does individual have fair skin or a family history of melanoma?
  • Is individual immunocompromised?
  • Does individual report a history of excessive sunlight exposure or sunburns at an early age?
  • Were local and distant metastasis assessed with appropriate tests and diagnostic imaging?

Regarding treatment:

  • What stage was the disease at diagnosis?
  • Was the skin lesion surgically removed?
  • Was the lesion's thickness greater than 1.5 mm?
  • Was lesion excised completely along with surrounding tissue? Were targeted lymph nodes removed?
  • Will individual avoid sunlight, use sunscreen, and wear protective clothing?
  • Was it necessary for individual to undergo adjuvant chemotherapy, radiation treatment, interferon, or biologic therapy?
  • If cancer has metastasized, has individual considered enrolling in a clinical trial?

Regarding prognosis:

  • What stage is the melanoma?
  • Has the melanoma spread to a local lymph node? Was it removed?
  • Has metastasis to other organs occurred? Has it been treated with appropriate adjuvant therapy after surgery?
  • What is the individual’s response to adjuvant therapy?
  • Is individual immunocompromised?
  • Can individual's employer accommodate any necessary work restrictions?

Source: Medical Disability Advisor



References

Cited

Mayo Clinic Staff. "Melanoma." MayoClinic.com. 3 Jun. 2008. Mayo Foundation for Medical Education and Research. 23 Sep. 2009 <http://www.mayoclinic.com/health/melanoma/DS00439>.

Swetter, Susan. "Malignant Melanoma." eMedicine. Eds. Gunter Borg, et al. 12 Feb. 2009. Medscape. 2 Sep. 2009 <http://emedicine.medscape.com/article/1100753-overview>.

Wells, Gregory. "Melanoma." The Merck Manual of Diagnosis and Therapy. Eds. Robert S. Porter, et al. 18th ed. Whitehouse Station, NJ: Merck and Company, Inc., 2008. Merck Manual of Diagnosis and Therapy. Aug. 2008. Merck & Co., Inc. 2 Sep. 2009 <http://www.merck.com/mmpe/sec10/ch128/ch128e.html>.

Source: Medical Disability Advisor






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