1. Malignant melanoma melanoma

2. Malignant melanoma -malignant tumor arising from melanocytes -tendency to early lymphogenic and haematogenic metastasing -fast increasing incidence of melanoma in the world middle Europe 1930:1-2 patients/ 100 000 persons 1960: 5 patients/100 000 1990: 10-14 patients/100 000 2010:14-16 patients/100 000 Australia : 60 patients/ 100 000 persons Africa, Asia : 0,1-0,5 patients/ 100 000 persons -Approx. men=women -54 years:average age of melanoma patient -Arising number of thin melanomas „low-risk“ due to campaigns

3. Pathogenesis of malignant melanoma -genetics (FAMMM syndrome, syndrome of dysplastic naevi) -large congenital naevi, multiple dysplastic naevi -immunosuppression (HIV, transplantation) -UV-light

4. Highest incidence and mortality: men (54 years+) Picture

5. Highest incidence and mortality: men (54 years+) Picture

6. -FAMMM syndrome(familial atypical multiple mole and melanoma) sy. -Syndrome of dysplastic naevi Genetics 30-50% melanomas arising in a pigment mole Picture

7. Congenital naevi N. giganteus (5-7 % risk of melanoma) Picture

8. Congenital naevi small 2 cm medium-sized 2-20 cm large -above 20 cm (MM 5-7 %) Picture

9. UV-light -intermittent intensive UV-exposition -chronical UV-exposition(lentigo maligna melanoma, epithelial tumors) -skin fototype (I,II) -sunburns in childhood -frequent vacation (close to equator) UVA: 320-400 nm UVB: 280-320 nm UVC: 40-280 nm fototypesunburnpigmentation Ialwaysnever IIalwayssometimes IIIsometimesalways IVneveralways Vdark skin

10. Distribution of melanomas in men and women Picture

11. SSM (superficial spreading melanoma) -65 % -horizontal growth in the initial phase, later verticalization (small nodules) -relatively good prognosis due to long history Picture

12. SSM (superficial spreading melanoma) Picture

13. Nodular melanoma - 20 % -initially smooth surface, later verrucous or ulcerating -short history due to rapid vertical growth -unfavourable prognosis Picture

14. Nodular melanoma Picture

15. Lentigo maligna melanoma - 10 % -arising from lentigo maligna (praecancerosis) -face, hands, scalp (sun-exposed areas)) -elder people -relatively good prognosis due to long history and location Picture

16. UV light intermittent intensive UV-exposition chronical UV-exposition lentigo maligna melanoma Picture

17. Lentigo maligna melanoma Picture

18. Acrolentiginous melanoma - 5 % -palms, soles, subungual, oral or genital mucosa -initially smooth surface, later verrucous or ulcerating -bleeding due to mechanical trauma -diff. diagnosis: subungual haemorrhage -unfavourable prognosis Picture

19. Acrolentiginous melanoma Picture

20. Acrolentiginous melanoma Picture

21. Rare forms of melanoma - 5 % Amelanotic melanoma -difficult diagnostics -often nodular, erodating nodules on extremities -metastases are also amelanotic Mucosal melanoma Occult melanoma Picture

22. Rare forms of melanoma Picture

23. Mucosal melanoma Picture

24. Diagnostics -history early phase (rapid growth, change of colour, regression) late phase (bleeding, itching, inflammation, ulceration) -ABCDE rules -dermoscopy -histological examination (never diagnostic incision)

25. ABCDE rules asymmetry border colourdiameter elevation Picture

26. Diagnostics 80 % 92-95 % Picture

27. Dermoscopy pigment network hyperpigmentation brown globules blue-white veil Picture

28. Histological examination Breslow index –exact thickness in mm Picture

29. I: tumor cells in epidermis II: tumor cells in str. papillare III: tumor cells infiltrating upper corium IV: tumor cells infiltrating entire corium V: tumor cells infiltrating subcutis Clark classification Histological examination Picture

30. Histological examination Melanoma Melanoma cells are in nests and have frequent mitosis Picture

31. Therapy !Excision with safety margin! Therapy according to the stage High risk patients: immunotherapy interferon alfa x peptide vaccines Visceral metastases: chemotherapy Dacarbazin (lung, liver, bones, brain) Bone and brain metastases: irradiation

32. Surgery of primary melanoma Tumor thicknessSafety margin Tis0,5 cm <2 mm1 cm >2 mm2 cm Picture

33. Lymph node and skin metastasis Picture

34. Skin metastasis Picture

35. Sentinel lymph node important for prognosis of the patient 1.draining lymph node I. affected SLN: radical lymphadenectomy II. unaffected SLN: no further surgical intervention Picture

36. SLN- lymphoscintigraphy Dosis of 0,4 ml Tc 99 as colloid Gamma camera Lymphoscintigraphy- dynamics 20 min SLN marked with Tc

37. Patent blue Upper extremity: min. 10-20 min Lower extremity: min. 30 min Sentinel lymph node-patent blue Picture

38. Sentinel lymph node I. II. Picture