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Melanoma

Melanoma, the sixth most common cancer, is highly lethal despite accounting for only 1% of skin cancers. This article discusses risk factors, clinical prediction rules, growth patterns, diagnostic tests, and treatment options for melanoma. It includes details on different types of melanoma, diagnostic tests like excisional biopsy, and guidelines for surgical margins based on tumor thickness. The text also covers the management of head and neck, subungual, and plantar melanomas, as well as treatments for positive sentinel nodes and metastatic melanoma.

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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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