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11/2/2014.

Malignant Melanoma Research Paper


Malignant melanoma is a rare skin cancer arising from the cells that produces melanin
(melanocyte) found between the epidermis (top skin layer) and the dermis (middle layer). Other
areas of the body that can be affected by melanoma include areas such as the eyes, mouth,
genitals, and anal areas. Basal and Squamous cell cancers of the skin are more common, but
melanoma is far more dangerous (cancer.org).
Epidemiology:
ASRT- Radiation Therapist, 2014 estimates 76,100 new cases of melanomas will be
diagnosed (about 43,890 in men and 32,210 in women), and about 9,710 people are expected to
die from it (6,470 men and 3,240 women) with whites being 23 times more than African
Americans to be affected by the disease. It has been on the rise for the past 30years becoming the
5th most tumor type among men.
Etiology:
The cause of melanoma is unknown but risk factors include: Exposure to UV rays (sunlight) which is the major risk factor for most melanoma, age (older
people and children under 30 years), gender, light-colored skin, history of childhood sunburn,
family history, tanning, and xeroderma pigmentosum (inherited condition- unable to repair
damage cause by sunlight) cancer.org, 2014.

Signs/Symptoms:

According to the American Cancer Society, ABCDE rule is a guide that warrants you to
notify your doctor for check up.
o Self-examination for ABCDE rule for mole.
A Difference in matching of some of the moles (Asymmetry).
B The border edges are irregular, notched, or blurred.
C Non uniform color which may include shades of brown or black, patches of pink.
D The spot is larger than 6 millimeters diameter across or smaller.
E Evolving mole size, shape, or color.
o Unusual sores that does not heal
o

lumps,

changes in the way an existing mole looks or feels.

Clinical Presentation:
Most malignant melanoma grow slowly at first and it is confined to the epidermis (radial
growth phase) with good prognostics if treated. Left untreated, it proceeds to the vertical growth
phase which invades the dermis, subcutaneous layer and other tissues. The prognostic at this
level is poor with distant metastases on the skin, gastrointestinal tract, lungs, liver, and other soft
tissues. Malignant melanoma spreads to the brain more often than any other form of cancer
(ASRT-Radiation Therapist, 2014 Vol. 23 No.1).
Diagnosis, staging and Work-up.
Diagnosis is based on physical examination following the sign and symptoms brought to the
doctors attention couple with medical history. Biopsies are done within suspected areas as
demanded by the doctor. If there is a possible spread, sentinel lymph node biopsy is done or
imaging modalities such as CT, MRI and PET may also be used. The National Comprehensive

Cancer Network, pathology report considers factors such as breslow thickness, ulceration status,
mitotic rate, Clark level, microsatellite status and histologic subtype during diagnosis, staging
and diagnostic work-up. Breslow thickness (expressed in mm) is determined by the extend of the
tumor penetration beneath the skin. American Joint Commission on Cancer (AJCC) uses the
TNM system to stage melanoma.
American Cancer society estimate the 5 year survival rate based on the stage of the disease,
age of the person, genetic changes in the cancer cells and the response to treatment. The 5year
survival rate is listed below as follows: Stage IA: 5-year survival rate = 97%, and 10 year = 95%.
Stage IB: 5-year survival rate = 92%, and 10-year survival = 86%.
Stage IIA: 5-year survival rate = 81%, and 10-year survival = 67%.
Stage IIB: 5-year survival rate = 70%, and 10-year survival = 57%.
Stage IIC: 5-year survival rate = 53%, and 10-year survival = 40%.
Stage IIIA: 5-year survival rate = 78%, and 10-year survival = 68%.*
Stage IIIB: 5-year survival rate = 59%, and 10-year survival = 43%.
Stage IIIC: 5-year survival rate = 40%, and 10-year survival = 24%.
Stage IV: 5-year survival rate = 15% - 20%, and 10-year survival = 10% - 15%
The Principle and Practice of Radiation Therapy, 3rd ed. described the TNM system as
follows: TX Primary tumor cannot be assessed.
T0 No evidence of primary tumor
Tis Melanoma in-situ
T1 (a & b) Tumor is 1 mm thick, without or with ulceration.

T2 (a & b) Tumor is 1 2mm without or with ulceration respectively.


T3 (a & b) Tumor is 2 4mm, without or with ulceration respectively.
T4 (a & b) Tumor is 4mm without or with ulceration respectively.
Routes of Spread:
Malignant melanoma first spreads through lymphatic system to other areas of the body and
through the blood (hematogenous). Satellite lesions are those found within 2cm of the primary
tumor and lesions beyond 2cm within the regional lymph node basin is considered metastasis.
Distant metastasis moves to other regions of the body, gastrointestinal tract (GI-Track), lungs,
liver, and other soft tissues. When this happens, the tumor areas are considered secondary
cancers and are an indication of an advanced stage of cancer.
Simulation and Immobilization:
The simulation position following removal of axillary nodes, requires the patient to be head first
supine (HFS), immobilized in a supine position with one arm by the side and the other hand on
the hip and the elbow pointed outward. Markings are done for reproducibility of the treatment
setup. It should also be noted that the importance of simulation is to evaluate the extend of the
tumor, so as to help the doctor with planning the treatment and contributes to the patient
prognostics (ASRT-Radiation Therapist, 2014 Vol. 23 No.1).
Treatment:
According to ASRT-Radiation Therapist, 2014 Vol. 23 No.1, states that the first tumor
treated with radiation was melanoma and radiation still remains an important treatment option in
advance cases of melanoma. Surgery is the treatment of choice for melanoma.

i. Radiation:

Radiation is recommended when lymph nodes are involved and it has been surgically removed,
or when the surgical margins test positive. Also use to relieve symptoms caused by the spread of
melanoma. Mixed beam technique is usually used following the involvement of lymph nodes and
the energies ranges from 6-22MeV and 18MV. Lower energy electrons fields are used to treat
superficial nodes and the entire extend of the scar, while high energy photons use for deep nodes
such as the iliac nodes (ASRT-Radiation Therapist, 2014 Vol. 23 No.1).
The Dose to melanoma depends on the area being treated. For example skin and mucosal
melanoma in the oral cavity, vagina and the anus can be treated with doses of 60 70cGy with
200-300cGy per fraction. Also, lentigo maligna can be treated with 45cGy with 300cGy per
fraction or 5000-6000cGy in 200cGy per fraction (Radiation Oncology-Management Decisions).
Treatment Borders:
The target volume for adjuvant radiation following lymph node dissection typically includes
the primary site scar with a 3- to 4-cm margin. In an event of surgery in the axillary region,
radiation fields will include the axillary lymph nodes, the supraclavicular fossa, and the low
cervical nodes.
Radiation Side Effects:
According to ASRT-Radiation Therapist, 2014 Vol. 23 No.1, radiation side effects depends
on the area being treated and some effects includes:

Alopecia within the area being treated.

Fatigue

Nausea

Loss of appetite and weight loss

Dry and moist desquamation

Late adverse effects include hyper and hypo pigmentation, not leaving out lymph-edema.

ii. Surgery:
a. Small low risk tumors are removed using cryosurgery with the use of liquid nitrogen or
carbon dioxide. Within weeks the form scab falls off.
b. Mohs micrographic surgery is the surgical method with the highest cure rate and best
cosmetic effects. It is performed with the use of anesthesia around critical structures such
as the eye, nose, lips, and ears. It is the surgical removal of very thin layer of tissue and it
is immediately examined under the microscope to determine whether cancerous cells are
present; and if present, another thin layer is removed and examined until no malignant
cells found (ASRT-Radiation Therapist, 2014 Vol. 23 No.1).
iii. Immunotherapy/chemotherapy
The US Food and Drug Administration (FDA) has approved an immunotherapy drug
(pembrolizumab) to treat advance cases of melanoma which cannot be treated using surgery or
other drugs. This drug is a type of anti PD-1 drug. Melanoma cells often have a protein called
PD-L1 on their surface that helps them avoid being found and destroyed by the bodys immune
system. Drugs that block the PD-L1 protein, or the corresponding PD-1 protein on immune cells,
can help the immune system recognize the melanoma cells and attack them. Surgery still remains
the treatment of choice for melanomas (American Cancer Society, 2014).
Chemotherapy is usually not as effective in melanoma as it is in some other types of cancer, but
it may relieve symptoms or extend survival for some patients. If use, Temozolomide, paclitaxel.
Carmustine, Cisplatin to name a few.

Work Cited

Washington, C., & Leaver, D. (2009). Principles and Practice of Radiation


Therapy. (3rd Ed.)

Harting, D. (2014). Asrt essential education. Radiation Therapist, 23(1), 51-70.


Retrieved from http://www.asrt.org

Chao, C., Perez, C., & Brady, L. (2000). Radiation Oncology-Management


Decisions. (p. 112). Philadelphia: Lippincott-Raven.

Malignant melanoma (2014). Retrieved from http://cancer.org

CONSIDERATION FOR POWER POINT PRSENTATION\


Eventhough self examination ois vital, the only accurate way to diagnose melanoma is
through biopsy.

Punch biopsy. During a punch biopsy, your doctor uses a tool with a circular blade. The
blade is pressed into the skin around a suspicious mole, and a round piece of skin is removed.

Excisional biopsy. In this procedure, the entire mole or growth is removed along with a
small border of normal-appearing skin.

Incisional biopsy. With an incisional biopsy, only the most irregular part of a mole or
growth is taken for laboratory analysis.

The type of skin biopsy procedure you undergo will depend on your situation. Doctors prefer to
use punch biopsy or excisional biopsy to remove the entire growth whenever possible. Incisional
biopsy may be used when other techniques can't easily be completed.
Sentinel Node Biopsy: This procedure involves
intradermal injection of a radiopharmaceutical such as technetium Tc 99m sulfur colloid at
multiple sites around the primary lesion to help visualize lymphatic drainage patterns.
The status of the sentinel lymph node is crucial, as it
provides important prognostic information, helps physicians
make subsequent treatment decisions, and can help
identify patients who are candidates for clinical trials.

Keratoses

Asymmetrical melanoma with irregular


borders with an uneven color

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