1. MELANOMA

3. Melanoma

4. Melanoma Represents 4% of all cancers
Most common malignancy in women aged
Incidence is rising faster than any other cancer
Lifetime risk of developing melanoma now about 1 in 70
30% arise in existing nevi

5. Risk Factors Fair skin Presence of atypical nevi
Personal history of melanoma
Family history of atypical nevi or melanoma
History of blistering sunburn
Congenital nevi (incidence increases with increasing size)

6. ABCDs of Melanoma Recognition
Asymmetry - one half of lesion does not look like the other
Borders - Scalloped border or focal extension into surrounding skin
Color variegation - varying hues and colors (black, brown, red, blue and white
Diameter - >6mm

7. Superficial Spreading Melanoma
Most common subtype accounting for 70-80% of melanomas
F > M mostly Caucasians
Most often on trunk and extremities
Tend to be > 6mm
Spread laterally for years before developing nodules

8. Nodular Melanoma Account for 10-15% of melanomas M = F
Most often found on the extremities
Evolve over months and extend vertically with little lateral spread

9. Lentigo Maligna and Lentigo Maligna Melanoma
Account for 5-10% of melanomas
Arise most often on the face, neck or dorsal arms in older Caucasians
M = F. Develop over years or decades
Lentigo Maligna represents in situ lesion and 5% progress to invasive LMM

10. Amelanotic Melanoma Descriptive term for non- pigmented melanoma
Any type can be amelanotic
2% of all melanomas are amelanotic
Malignant cells produce little or no pigment
Poorer prognosis due to delayed diagnosis

11. Acral Lentiginous Melanoma
Accounts for 7% of melanomas
Occurs on hands, feet, nails and mucous membranes
Most common melanoma in blacks and asians > 50%
Least common in Caucasians
Leading cause of skin cancer deaths

12. Acral Lentiginous Melanoma
Most patients are between
Usually slow growing
Often difficult to detect early which leads to poor prognosis
Often begins as a brown/black streak under a nail or bruise like area on acral skin

13. Acral Lentiginous Melanoma
Diagnosis is by clinical suspicion and tissue biopsy
Treatment is surgical excision with appropriate margins and in some cases requires amputation
Additional studies(PET, CT, SNL) are performed if indicated

14. Workup
All suspicious lesions should be biopsied. This does not increase the risk of metastases.
Excisional or punch biopsy allows for accurate measurement of Breslow’s depth. Never shave biopsy a suspected melanoma.
Breslow’s depth, ulceration and mitotic rate are most important features histologically
Sentinel lymph node biopsy should be done on all melanomas >=1mm
For patients with positive sentinel nodes, PET/CT scanning should be performed to rule out distant metastases

15. Treatment
Wide local excision with adequate margins is treatment of choice
Appropriate margin is determined by Breslow’s depth
Melanoma in situ requires a margin of 0.5 cm
Melanoma up to 2.0 mm requires a 1.0 cm margin with full thickness dermis and subcutaneous fat
Melanoma > 2.0 mm requires a 2.0 cm margin with full thickness dermis and subcutaneous fat

16. Sentinel Node Biopsy
Lymphoscintigraphy procedure where a sulfur colloid tagged with technetium-99m is injected at the site of the initial tumor and followed to the draining lymph node basin
15 minutes prior to dissection blue dye is injected at the same site.
The nodal basin is then dissected and inspected for those nodes that take up the dye and are shown by Geiger counter to have taken up the radioactive material. These are the sentinel node(s)

17. Sentinel Nodes
Once identified the sentinel nodes are removed and examined histologically for evidence of tumor spread
If sentinel nodes are positive full elective lymph node dissection may be done as well as further staging workup
If sentinel node(s) is negative no further workup is required

21. Adjuvant Therapy ELND has shown no real increase in survival
Adjuvant therapy with interferon was often recommended for those with advance stages of disease but did not significantly increase survival
Interferon has numerous side effects (flu like symptoms) making it difficult to complete treatment

22. Adjuvant Therapy
Zelboraf (vemurafenib) - For patients with metastatic melanoma with tumors that express a gene mutation called BRAF V600E.
BRAF helps regulate cell growth. The variant of BRAF targeted by Zelboraf is a gene mutation that allows melanoma cancer cells to spread
Almost 50 percent of all melanoma tumors have the BRAF genetic mutation
Not yet clear how long Zelboraf can increase melanoma survival.

23. Adjuvant Therapy
Yervoy (ipilimumab) - For the treatment of late-stage, metastatic melanoma
Patients taking Yervoy survived an average of 10 months after starting treatment
A monoclonal antibody that blocks a crucial switch on immune cells called CTLA-4. Cancers use this switch to turn off the body's anticancer immune responses.
Nearly 13% of patients taking Yervoy had severe or fatal autoimmune reactions.

24. Melanoma Survival
Stage IA: The 5-year survival rate is around 97%. The 10- year survival is around 95%.
Stage IB: The 5-year survival rate is around 92%. The 10- year survival is around 86%.
Stage IIA: The 5-year survival rate is around 81%. The 10- year survival is around 67%.
Stage IIB: The 5-year survival rate is around 70%. The 10- year survival is around 57%.
Stage IIC: The 5-year survival rate is around 53%. The 10- year survival is around 40%.

25. Melanoma Survival
Stage IIIA: The 5-year survival rate is around 78%. The 10-year survival is around 68%.
Stage IIIB: The 5-year survival rate is around 59%. The 10-year survival is around 43%.
Stage IIIC: The 5-year survival rate is around 40%. The 10-year survival is around 24%.
Stage IV: The 5-year survival rate for stage IV melanoma is about 15% to 20%. The 10-year survival is about 10% to 15%.

26. Prevention Wear protective clothing
Always use sunscreen SPF Must block both UVA and UVB
Avoid midday sun 10 am - 3 pm
Self skin exams
Avoid sunburn

27. Follow Up
All melanoma patients should have semi- annual skin examinations including lymph node assessment for 2-3 years followed by annual exams for their lifetime
Appropriate scanning should continue as indicated
All first degree relatives should have a baseline skin exam and annual exams for life