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MALIGNANT MELANOMA

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Definition
Aetiology
Pathopyhsiology
Prevalence/frequency
Pathology/staging
Clinical features
Workup
Treatment
Prognosis/followup
New issues

definition
• A neoplasm of the melanocytes or of the cells
that develop from melanocytes.
• Sites include
-skin
-GIT
-GUT
-leptomeninges
-eyes

-lymph nodes with no primary

• Highest incidence is in Queensland. • Lifetime risk for a US born is 1 in 55.epidemiology • ACS estimates about 68720 cases by 2009 with a CFR 8420 • CFR 3x all non melanoma skin cancers • Incidence increases by 5-7% each year. . australia about 57/100000 per year.

epidem • Most rapid increase in men. . in females second to lung cancer. • Medan age at diagnosis is 59.

2:1 • Age. 20% younger than 40yrs. All ages but rare in children <10yrs average age 57yrs.CDK4. Men: females 1. • Sex. Commoner in whites than in blacks and asians. CDKN2A(p16). • Genes implicated.Aetiology • Race.RB1. 75% patients younger than 70yrs.ras • CDKN2A(p19) – tumor suppressor .

• Preccussor lesions are nevi (dysplastic.pathophysiology • Originate from melanocytes which arise from neural crest cells. congenital. • Usually develop in or near a preccussor lesion but may arise denovo.cellular blue). .

Superficial spreading melanomas~ 75% -nodular melanomas ~10-15% -Lentigo maligna melanomas ~10-15% -Acral lentiginous melanoma .pathology • Histological forms .mucosal lentiginous melanoma • 2 growth phases -Radial -vertical .

Non ulcerated .

ulcerated .

with ulceration .<1.0mm T2 – 1.01 -4.0mm • a –without ulceration • b.0mm T4 ->4.0mm T3 -2.Staging by AJCC • • • • • TIS – tumour in situ T1 .01-2.

>4 nodes .Nodal involvement • • • • No – no nodes N1 – 1 node involoved N2 – 2 0r 3 nodes N3 .

distant subcut or L/Ns . a-micrometases b-macrometatases c-intransit mets with metastatic L/Ns .metases • • • • Mo M1 M2 M3 -no distant metasases .lung mets .all other viscera -elevated LDH not attributable to any other cause.

Any T any N >M1 .ToNoMo 1A .T1aNoMo 1B .any T N2cMo or any T N3Mo IV .T1bNoMo or T2aNoMo IIA -T2bNoMo or T3aNoMo IIB .TNM groupings • • • • • • • • • • 0 .T3bNoMo or T4bNoMo IIC – T4b NoMo IIIA –T1-T4a N1b Mo IIIB – T1-T4a N2b Mo IIIC .

Clark's Classification (level of invasion) – Level I .Tumor extends into papillary dermis – Level III .Tumor extends to interface between papillary and reticular dermis – Level IV .All tumor cells above basement membrane (in situ) – Level II .Tumor extends between bundles of collagen of reticular dermis (extends into reticular dermis) – Level V .Tumor invasion of subcutaneous tissue .

76-1.Breslow classification • Breslow classification (thickness) – – – – Less than or equal to 0.50 mm 1.0 mm • Thickness Thin < 0.0 mm Greater than or equal to 4.51-4.75 mm 0.75 mm Intermediate 1-4 mm Thick >4mm Nodes 60% >60% Metastases Prognosis 90% <20% 60-80% >70% <50% .

Clinical features • • • • • • • • • • Family history History of previous melanoma Sun exposure Moles and premalignant lesions Total body skin examination A -asymmetry B -border irregularity C -color changes D –diameter Lymph node examination .

Differential diagnosis • • • • Basal cell carcinoma Lentigo maligna melanoma Mycosis fungoides Benign melanotic lesions .

workup • LAB -CBC -chemistry panel .LFTs -LDH (for followup) .

imaging • • • • Mainly for staging Chest radiograph CT or MRI of the brain PET scan .

saucerization 1-3mm) -incisional if big lesion or in cosmetic areas.procedures • Principles of biopsy -excisional bx(elliptical. punch. -shave biopsy contra indicated it compromises the Breslow thickness. -surgical re-excision with tumour free margins .

Biopsy report • • • • • • Breslow thickness Ulceration Clark’s level Mitotic rate/mm2 Peripheral or deep margin status satellitosis .

01 – 2mm 1 – 2cm 2.0mm 1.0cm 1.5cm < 1.Principles of surgical margins for wide excision Tumour thickness Recommended clinical margin Ca in situ 0.01 – 4mm 2cm > 4mm 2cm .

. . • Or if seen on pelvic CT scan or a +ve cloquet’s node.those with no clinically enlarged nodes LND may add no survival benefit.>4mm LND may not be beneficial .Lymph node dissection • For adequacy of regional L/N dissection • Elective iliac and obturator node dissection necessary if superficial nodes are +ve.if >60yrs ?LND .

IOLM • Guidelines should not replace good clinical judgement or individualisation of reatment.SLNB . .Lymph node dissection .

single agent dacrbazine(DTIC) 2.Carmustine 7 tamoxifen) . combination CVD(cispaltin. DTIC. vinblastine $DTIC) or CDCT(ciplastin.treatment • Medical -adjuvant chemotherapy for high risk patients .Chemotherapy 1.

others • Immunotherapy with high dose IL-2 • Melanoma vaccines and gene therapy • Biological therapies including IFN alpha .

prognosis • Estimated survivals for stage stage 5yr survival < 1.0mm thick 90% Local disease 50-90% Stage III & above 20-70% Distant mets <10% .

Predictors of prognosis • • • • • Nodal status Presence of tumour ulceration Extranodal tumour extension Site of distant metastases Elevated LDH .

-Chest radiology.LDH.CBC every 6-12mths -CT for suspicious cases .followup no stage followup 1 Stage 0 -annual skin exam for life -educate patient on a monthly self skin exam 2 Stage 1A -examination 3-12mths for 5yrs then annually for life -patient education 3 Stage 1B-IV -assessment 3-6mths for 2yrs. then 3-12mths for 2yrs then annually there after.

•THANK YOU ALL .