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Melanoma

Melanoma. Hai Ho, M.D. Department of Family Practice. Epidemiology. Sixth most common cancer Incidence increases from 1/1500 in 1930 to 1/75 in 2000 1% of skin cancer but account for 60% of skin cancer death. Risk factors?. Sun exposure Intermittent intense exposure Childhood

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Melanoma

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  1. Melanoma Hai Ho, M.D. Department of Family Practice

  2. Epidemiology • Sixth most common cancer • Incidence increases from 1/1500 in 1930 to 1/75 in 2000 • 1% of skin cancer but account for 60% of skin cancer death

  3. Risk factors? • Sun exposure • Intermittent intense exposure • Childhood • UVB > UVA – higher incidence near equator • Tanning bed

  4. Clinical prediction rule American Cancer Society’s ABCDE

  5. A

  6. B

  7. C

  8. D Melanoma could occur in lesions less than 6 mm

  9. E Elevation or Enlargement by patient report

  10. Sensitivity of ABCDE rule If melanoma truly exists, the rule will detect it 92-97% (average 93%) of the time, when one criterion is met

  11. Caution • If none of the criteria is met, 99.8% chance that the lesion is not a melanoma (high negative predictive value) • May miss amelanotic melanomas and melanomas changing in size

  12. Growth patterns • Radial growth • Lasts for months to years • Growth and regression due to restraint by immunologic system • Horizontal and vertical growth • More poorly differentiated • Produce nodule or mass

  13. Superficial spreading melanoma White = regression • 50% of melanoma cases • Common in middle age • Radial spread and regression

  14. Nodular melanoma • 20-25% of melanoma cases • Common in 5-6th decade • Vertical growth and no horizontal growth phase

  15. Lentigo maligna melanoma Lentigo maligna Lentigo maligna melanoma • 15% of melanoma cases • Elderly – 6-7th decade • Lentigo maligna • Horizontal growth phase for years • Bizarre shapes from years of growth and regression • Transform to lentigo maligna melanoma

  16. Acral-lentigious melanoma • 10% of melanoma cases • In palms, soles, terminal phalanges, and mucous membrane • Growth phase similar to lentigo maligna and lentigo maligna melanoma • Aggressive tumor and early metastasis

  17. Diagnostic Tests

  18. Excisional biopsy Preferred method – deepest level of penetration for staging

  19. Punch biopsy Stretch the skin perpendicular to the skin line Subcutaneous fats Wound <4mm may not be sutured

  20. Shaving Never because prognosis and treatment are based on the level and depth of invasion

  21. Pathology • Depth of invasion • Growth pattern (nodular, superficial spreading, etc.) • Margin status • Presence or absence of ulceration

  22. Depth of invasion • Breslow • Measure the actual thickness • More reproducible and accurate in determining prognosis • Clark • Report by anatomical site • Significant if tumor ≥ 1mm

  23. Indications for regional node biopsy • Thickness 1-4 mm • Thickness < 1mm • Has <10% of nodal metastasis  no biopsy • Ulceration, truncal location, and male gender, either alone or in combination  consider biopsy to evaluate nodal metastasis • Thickness > 4mm • Has 65-70% distant metastasis  no biopsy

  24. Histological examination of nodes • Reverse transcriptase polymerase chain reaction (RT-PCR) assaydetects of tyrosinase messenger RNA, a melanocyte-specific marker, in lymph nodes with metastasis • Immunohistochemistry techniques

  25. Staging • Depth of invasion • Regional nodal metastasis • Distance metastasis

  26. Survival rate

  27. LDH Prognostic indicator for distant metastasis in stage IV

  28. Treatment

  29. Cutaneous excision Recommendations from Academy of Dermatology • A margin of 0.5 cm of normal skin is recommended for in situ melanomas. • A 1 cm margin is recommended for melanomas <2 mm thick • A 2 cm margin is recommended for melanomas 2 mm thick

  30. Other recommendations • Surgical margin of 3 cm for T3 (2.1 to 4.0 mm) or T4 (>4 mm) primary tumors • No correlation between thickness > 4mm and surgical margin (Heaton et al. Ann Surg Oncol 1998) • In >4mm thickness, outcome is probably based more on regional and distant metastasis

  31. Head and neck melanomas • Face and scalp – high recurrence rate • Complex regional node drainage • Parotid and cervical lymphatics are common sites of spread • Parotid node dissection – risk of CN VII injury • Limited skin – skin graft • Post-op adjuvant radiation for unsatisfactory margin and desmoplastic neurotropic melanomas

  32. Subungual melanoma • Fingers • Amputation DIP • Cutaneous excision and skin graft for proximal lesions • Toes • Amputation at MTP

  33. Plantar melanoma Cutaneous excision with skin graft due to lack of surplus skin

  34. Positive sentinel nodes Regional lymph node dissection

  35. Noncerebral metastatic melanoma • Cytotoxic chemotherapy • Immunotherapy such as interferon • Pallative • Radiation • Surgery

  36. Cerebral metastatic melanoma • Surgery • Whole brain radiation therapy • And/or stereotactic radiosurgery

  37. The End

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