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Melanoma Hai Ho, M.D. Department of Family Practice.
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Transcript of Melanoma Hai Ho, M.D. Department of Family Practice.
![Page 1: Melanoma Hai Ho, M.D. Department of Family Practice.](https://reader035.fdocuments.in/reader035/viewer/2022062421/56649dd05503460f94ac5ce1/html5/thumbnails/1.jpg)
Melanoma
Hai Ho, M.D.
Department of Family Practice
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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
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Risk factors?
Sun exposure Intermittent intense exposure Childhood
UVB > UVA – higher incidence near equator
Tanning bed
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Clinical prediction rule
American Cancer Society’s
ABCDE
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A
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B
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C
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D
Melanoma could occur in lesions less than 6 mm
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E
Elevation or Enlargement by patient report
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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
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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
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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
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Superficial spreading melanoma
50% of melanoma cases Common in middle age Radial spread and regression
White = regression
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Nodular melanoma
20-25% of melanoma cases Common in 5-6th decade Vertical growth and no horizontal growth
phase
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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
Lentigo maligna
Lentigo maligna melanoma
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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
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Excisional biopsy
Preferred method – deepest level of penetration for staging
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Punch biopsy
Wound <4mm may not be sutured
Subcutaneous fats
Stretch the skin perpendicular to the skin line
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Shaving
Never because prognosis and treatment are based on the level and depth of invasion
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Pathology
Depth of invasion Growth pattern (nodular, superficial
spreading, etc.) Margin status Presence or absence of ulceration
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Depth of invasion
Breslow
•Measure the actual thickness
•More reproducible and accurate in determining prognosis
Clark
•Report by anatomical site
•Significant if tumor ≥ 1mm
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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
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Histological examination of nodes
Reverse transcriptase polymerase chain reaction (RT-PCR) assay detects of tyrosinase messenger RNA, a melanocyte-specific marker, in lymph nodes with metastasis
Immunohistochemistry techniques
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Staging
Depth of invasion Regional nodal metastasis Distance metastasis
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Survival rate
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LDH
Prognostic indicator for distant metastasis in stage IV
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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
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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
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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
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Subungual melanoma
Fingers Amputation DIP Cutaneous excision and skin graft for
proximal lesions Toes
Amputation at MTP
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Plantar melanoma
Cutaneous excision with skin graft due to lack of surplus skin
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Positive sentinel nodes
Regional lymph node dissection
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Noncerebral metastatic melanoma
Cytotoxic chemotherapy Immunotherapy such as interferon Pallative
Radiation Surgery
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Cerebral metastatic melanoma
Surgery Whole brain radiation therapy And/or stereotactic radiosurgery
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