A Tan to Die For? Dan Magrill Taz Singh Laura Tincknell

Mr. RB History and Examination Background - 53 yrs, male, unemployed PC - RIF pain HPC - RIF pain for 1/12, radiating to the back. Loss of appetite, weight loss, tiredness, indigestion. Loose bowels 1/52, no blood or mucus. No N+V. PMH - No THREAD. L Testicular lump 18/12 - under observation.

History and Examination cont... FH - Paternal Grandfather - Bowel Ca. Father - Diverticulitis. SH - Unmarried, living alone and unemployed. Smoking 20+/day. Social drinker. SE: CVS - No chest pain, palpitations, breathlessness, orthopnoea, collapse, nocturnal dyspnoea...

History and Examination cont... Respiratory - No cough, wheeze, S.O.B, haemoptysis... GI - No N+V, rectal bleeding. But had indigestion, abdo pain, loose bowels, loss of appetite and weight loss... GU - No dysuria, frequency, haematuria, loin pain... Neurological - No headaches, dizziness, fits, collapse, weakness...

History and Examination cont O/E - Anxious, thin. T-37.5C, Pulse-regular, 75 bpm, BP 120/60 mmHg. O2 Sats- 97% CVS : Unremarkable Resp: Unremarkable Neuro: Unremarkable GI: Abdomen distended. Large firm mass in whole of abdomen apart from LIF which was tender on palpation. Liver percussed out to 35cm. BS present. PR-NAD

Plan USS: showing multiple liver metastases. Biopsy - melanoma. Ix to find primary: colonoscopy, CXR, ENT and opthalmology. Opthalmology report: R eye, smooth melanotic mass in anterior chamber. Management: Palliative Chemotherapy.

Presentation of a disease InIncidence AAge Surgeon’sSex GownGeography PhysiciansPredisposing factors MightMacro/Micro Pathology MakeManagement ProgressPrognosis

Incidence UK incidence of 10 / (per year) Rising by 7% every Year Least common of the “Big Three”, but highest mortality. Over last 20 years, incidence risen by over 80%

Age Superficial Spreading and Nodular Malignant Melanoma year olds Lentigo Malignant Melanoma - >60y.

Sex In the UK, women are affected twice as often as men In Men, the commonest site is the back In Women it is the Lower Leg (50%)

Geography The worldwide incidence is proportional to the Geographic Latitude Caucasians living closest to equator at highest risk This suggests an effect of UV radiation People living outside their indigenous climate are at risk

Predisposing Factors Fair Skin Red Hair Living close to Equator Freckles Exposure to the Sun Melanocytic Naevus (found in 30%) Genetics - 5% of Pt have Family History

Macro/Micro Pathology 1 Superficial Spreading Malignant Melanoma –50% of UK cases, especially female –Commonest in Lower Leg –Macular Tumour with Variable Pigmentation

Macro/Micro Pathology 2 Nodular Malignant Melanoma –Seen in 25% of UK cases, especially Male –Commonest site is the Trunk –Pigmented Nodule –Grows rapidly and can Ulcerate

Macro/Micro Pathology 3 Lentigo Malignant Melanoma –15% of UK cases –Malignant melanoma growing in long standing Lentigo Maligna These arise form sun damaged skin Often in elderly, especially who have worked outside for many years

Macro/Micro Pathology 4 Acral Lentiginous Malignant Melanoma –10% of UK cases –Commonest form in Mongoloids –Tumour affects Palms, Soles and Nail Beds –Often diagnosed late - poor prognosis

Staging Local Staging assessed using the BRESLOW method –Measured mm between granular cell layer and deepest identifiable melanoma cell Metastasis are uncommon if confined to epidermis

Diagnosis The following changes in a Naevus or Pigmented lesion –Size, usually a recent increase –Shape, irregular in outline –Colour, variation - darker or lighter –Inflammation, especially at edge –Crusting, may ooze or bleed –Itch

Differential Diagnosis Benign melanocytic naevus Seborrhoeic wart Haemangioma Dermatofibroma Pigmented Basal Cell Carcinoma Benign Lentigo

Management 1 Surgical Excision –If <1mm, use a 1cm clearance margin –If >1mm, need a 1-2cm clearance As this is quite a large area a skin graft may be indicated Regular follow up to detect recurrence –Local –Lymphatic, regional or distant –Blood Bourne - to distant sites (eg Liver)

Management 2 Elective Lymph node dissection and Sentinel node biopsy not recommended as routine. Radiotherapy of limited use –Interferon-alfa may increase survival if tumour >1.5mm thick

Prognosis Related to tumour depth 5 year survival: –<1mm95-100% –1-2mm80-96% –2.1-4mm60-75% –>4mm50%

Prevention and Public Education If caught early have good prognosis Public should be encouraged to visit doctor early if changing pigmented lesion Sun exposure should be discouraged –Especially if fair skinned or with multiple melanocytic naevi