Melanoma evaluation and management: expanding the role of the general practitioner in skin examination Meghan A. Rauchenstein February 16, 2006

Pathophysiology Cancer of melanocytes Uncontrolled proliferation Spreading horizontal = in situ Vertical spread through the basement membrane Infiltration to regional lymph nodes Spread into organs, bones and new skin sites

Pigmented Nevus

Dysplasia of MIS

Epidemiology Risk factors: –fair, freckled, blue eyes, burns without tanning –elderly (age) –50+ nevi, > 2 mm in diameter –3+ blistering sunburns, 3+ summer jobs Statistics: –57,000 metastatic cases this year –9,000 deaths –46,170 in situ diagnoses

Epidemology #1 CA women 25-29, #2 CA women behind BrCA 43% of white children under 12 had at least one sunburn last year Blacks present with more advanced disease than whites Uninsured/Medicaid present with late- stage disease

Dermoscopy Allows magnification of lesion Oil makes epithelium transparent Algorithms increase sensitivity and specificity Training sessions allow any practitioner to learn the technique Only used by 17-23% of US dermatologists

Dermatoscopes

Why do I need one? Standard practice for European PCPs United States in top 5 with highest incidence rates Inexpensive Improves accuracy in diagnosing melanoma Fewer benign excisions sent to lab

ABCD rule of dermoscopy score weight AIn 0, 1, or 2 axes; assess contour, colors and structures 0-2 X 1.3 BAbrupt ending of pigment at periphery in 0-8 segments 0-8 X 0.1 CWhite, red, tan, brown, blue-gray, black 1-6 X 0.5 DNetwork, structureless areas, streaks, dots, and globules 1-5 X 0.5 ScoreInterpretation <4.75Benign melanocytic lesion Suspicious lesion; close follow-up or excision recommended >5.45Lesion highly suspicious for melanoma

Menzies scoring method Negative features (both must be absent) Symmetry in color and shape A single color is observed Positive features (2 out of 9) Blue-white veil Focal collections of multiple, dark brown dots Peripheral black dots and globules Radial streaming Pseudopods Scarlike depigmentation 5-6 colors: black, gray, blue, red, dark brown, and tan Multiple “pepperlike” small, blue or gray dots. Localized, thickened, and irregular pigmented network

Pigmented benign nevus

Lesion excision

Patient outcomes Benign Malignant –May need to re-excise to get wider margins –Follow up with periodic exams –Check local lymph nodes for metastases –Refer to specialist

Metastatic melanoma FDA approved –Interferon α 2b –Proleukin ® (aldesleukin) –recombinant IL-2 –BCG: Bacille Calmette-Guérin –Chemotherapy –Radiation therapy Clinical trials –Vaccine therapy –PI-88

Any questions? References available upon request