1. Hai Ho, M.D. Department of Family Practice
Melanoma
Hai Ho, M.D.
Department of Family Practice

2. 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

3. Risk factors? Sun exposure
Intermittent intense exposure
Childhood
UVB > UVA – higher incidence near equator
Tanning bed

4. Patients at risk? Risk factor Relative risk
Atypical nevus syndrome with personal and family history of melanoma
500
Changing mole
>400
Atypical nevus syndrome with family history of melanoma
140
Age ≥ 15 88
Dysplastic moles
7-70

5. Clinical prediction rule
American Cancer Society’s
ABCDE

6. A

7. B

8. C

9. D
Melanoma could occur in lesions less than 6 mm

10. Elevation or Enlargement by patient report

11. 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

12. 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

13. Growth patterns Radial growth Horizontal and vertical 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

14. Superficial spreading melanoma
White = regression
50% of melanoma cases
Common in middle age
Radial spread and regression
Regression due to immunological system

15. Nodular melanoma 20-25% of melanoma cases Common in 5-6th decade
Vertical growth and no horizontal growth phase

16. 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

17. 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

18. Diagnostic Tests

19. Preferred method – deepest level of penetration for staging
Excisional biopsy
A local excisional biopsy with a 1 to 2 mm rim of normal appearing skin
Punch or incisional biopsies of large lesions permits the diagnosis of melanoma to be made in most cases, however an incisional biopsy may not provide accurate staging of tumor thickness unless the thickest portion of the lesion is sampled
Preferred method – deepest level of penetration for staging

20. Wound <4mm may not be sutured
Punch biopsy
Stretch the skin perpendicular to the skin line
FIGURE 1. Orienting a punch biopsy. (A) Just before performing the biopsy, the lines of least skin tension are determined. (B) The skin is stretched 90 degrees perpendicular to the lines of least skin tension using the nondominant hand. The punch biopsy is performed. Following relaxation of the distending hand, (C) the wound has an elliptical shape that can be closed with sutures parallel to the lines of least skin tension
Subcutaneous fats
Wound <4mm may not be sutured

21. Shaving
Never because prognosis and treatment are based on the level and depth of invasion

22. Pathology Depth of invasion
Growth pattern (nodular, superficial spreading, etc.)
Margin status
Presence or absence of ulceration
ten year survival was significantly lower for thin ( 1 mm) melanomas with ulceration compared to those without ulceration (76 versus 86 percent) [8]. Furthermore, ulceration of the primary melanoma was the only tumor feature that predicted an adverse outcome in patients with nodal metastases) (risk ratio, 1.58, 95 percent confidence interval [CI], 1.31 to 1.91).

23. Depth of invasion Breslow Clark Measure the actual thickness
More reproducible and accurate in determining prognosis
Clark
Report by anatomical site
Significant if tumor ≥ 1mm

24. 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

25. 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

26. Staging Depth of invasion Regional nodal metastasis
Distance metastasis

29. Survival rate

30. Prognostic indicator for distant metastasis in stage IV
LDH
Prognostic indicator for distant metastasis in stage IV

31. Treatment

32. 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

33. 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

34. 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

35. Subungual melanoma Fingers Toes Amputation DIP
Cutaneous excision and skin graft for proximal lesions
Toes
Amputation at MTP

36. Cutaneous excision with skin graft due to lack of surplus skin
Plantar melanoma
Cutaneous excision with skin graft due to lack of surplus skin

37. Positive sentinel nodes
Regional lymph node dissection

38. Noncerebral metastatic melanoma
Cytotoxic chemotherapy
Immunotherapy such as interferon
Pallative
Radiation
Surgery

39. Cerebral metastatic melanoma
Surgery
Whole brain radiation therapy
And/or stereotactic radiosurgery

40. The End