Malignant Melanoma Epidemiology, classification and surgical treatment
Incidence <ul><li>Increase by 6% per year (Sweden, USA) </li></ul><ul><li>Fastest increase of all malignancies </li></ul><...
Age and Sex <ul><li>Starts to appear from puberty </li></ul><ul><li>Median age 55 years for both sexes </li></ul><ul><li>A...
What’s new? <ul><li>Not very much. Early diagnosis surgical removal are most important </li></ul><ul><li>Less radical surg...
Survival <ul><li>Increased from 50% 1960 to 80% 1990 </li></ul><ul><li>Better for females than males </li></ul><ul><li>Wor...
Risk factors <ul><li>Fair skin </li></ul><ul><li>Sun exposure </li></ul><ul><li>Earlier melanoma (9.5 times) </li></ul><ul...
Diagnosis <ul><li>Symptoms: Pruritus </li></ul><ul><li>Signs: ABCDE </li></ul><ul><ul><li>A asymmetry of borders </li></ul...
Biopsy <ul><li>Small and accessible lesions </li></ul><ul><ul><li>Excision with 1 cm margins in suspicious lesions </li></...
Pathological reporting <ul><li>Note history and surgery </li></ul><ul><li>Formalin fixation </li></ul><ul><li>PAD: </li></...
Clark level of invasion <ul><li>Level 1:  confined to the epidermis </li></ul><ul><li>Level 2:  a few cells in the dermis ...
Breslow level of invasion <ul><li>Level 1:  0.0-0.75mm </li></ul><ul><li>Level 2:  0.76-1.50 mm </li></ul><ul><li>Level 3:...
Histogenetic type <ul><li>Superficial Spreading Melanoma (50-70%) </li></ul><ul><li>Nodular Melanoma (trunk) </li></ul><ul...
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tests <ul><li>Thorough history and clinical examination </li></ul><ul><li>Noninvasive screening problematic </li></ul><ul>...
ELM criteria: Results of 72 melanoma cases TnM: thin melanoma (<0.75 mm); TkM: thick melanoma (>0.75 mm) ELM criterion Pre...
 
Pigmented network + radial streaming Abnormal Vascolar pattern Thin Melanoma Thick Melanoma Gray, Blue, Shadow +
Melanoma  Clinic Diagnosis Melanoma < 0,75 mm Excision (1 cm) Melanoma >0,75 mm Excision (2-3 cm)  Lymph Node Biopsy Evalu...
Classificazione TNM del Melanoma Stadio pT N M Ia Ib pT1 pT2 N0 M0 II pT3 N0 M0 IIIa IIIb pT4 Ogni pT N0 N1,N2 M0 IV Ogni ...
pT  Tumore primitivo <ul><li>pTx  Il tumore primitivo non può essere definito </li></ul><ul><li>pT0  Non segni di tumore p...
N  Linfonodi regionali <ul><li>Nx   I linfonodi regionali non possono essere definiti </li></ul><ul><li>No   Non metastasi...
M   Metastasi a distanza <ul><li>Mx La presenza di metastasi a distanza non può essere accertata </li></ul><ul><li>M0 Non ...
AJCC Staging System for Melanoma <ul><li>Stage I : Localized </li></ul><ul><ul><li>T1a or b: <1.0 mm, non-ulcerated or ulc...
Local excision (based on thickness of tumour) <ul><li><0.75 mm:   1 cm margins </li></ul><ul><li>0.75 - 2mm:   2 cm margin...
Special locations <ul><li>The aim of excision is local control </li></ul><ul><li>Narrow excisional margins have not been p...
Regional lymph nodes <ul><li>Therapeutic lymphadenectomy of value (G öteborg – 27%  10-year survival) </li></ul><ul><li>El...
Sentinel biopsy concept <ul><li>To define the pathway from the melanoma site to the first draining lymph node by injecting...
Adjuvant therapy <ul><li>Interferon has been approved by the FDA in high risk melanomas </li></ul><ul><li>Toxic and expens...
5 year Survival <ul><li><0.76 mm 96% </li></ul><ul><li>0.76-1.49 mm 90% </li></ul><ul><li>1.50-2.49 mm 80% </li></ul><ul><...
Recurrences <ul><li>Regional  Lymph nodes </li></ul><ul><ul><li>Radical removal </li></ul></ul><ul><ul><li>inteferon </li>...
Distant metastases <ul><li>Remote soft tissue or nodal metastases </li></ul><ul><li>Visceral metastases (lung, liver, brai...
Follow-up <ul><li>Goals </li></ul><ul><ul><li>To detect a second primary melanoma (3-5%) </li></ul></ul><ul><ul><li>To det...
Upcoming SlideShare
Loading in...5
×

Malignant Melanoma

5,364

Published on

Published in: Health & Medicine, Sports
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
5,364
On Slideshare
0
From Embeds
0
Number of Embeds
3
Actions
Shares
0
Downloads
1,002
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Malignant Melanoma

  1. 1. Malignant Melanoma Epidemiology, classification and surgical treatment
  2. 2. Incidence <ul><li>Increase by 6% per year (Sweden, USA) </li></ul><ul><li>Fastest increase of all malignancies </li></ul><ul><li>6th most common cancer </li></ul>
  3. 3. Age and Sex <ul><li>Starts to appear from puberty </li></ul><ul><li>Median age 55 years for both sexes </li></ul><ul><li>About the same number in both sexes </li></ul><ul><li>In males the highest incidence and fastest increase are in trunk melanomas </li></ul><ul><li>In females the highest incidence and fastest increase are in melanomas of the lower leg </li></ul>
  4. 4. What’s new? <ul><li>Not very much. Early diagnosis surgical removal are most important </li></ul><ul><li>Less radical surgery (local removal and nodal dissections) </li></ul><ul><li>Lymphatic mapping (sentinel lymph node biopsy) </li></ul><ul><li>Interferon </li></ul>
  5. 5. Survival <ul><li>Increased from 50% 1960 to 80% 1990 </li></ul><ul><li>Better for females than males </li></ul><ul><li>Worst for melanomas on the trunk </li></ul>
  6. 6. Risk factors <ul><li>Fair skin </li></ul><ul><li>Sun exposure </li></ul><ul><li>Earlier melanoma (9.5 times) </li></ul><ul><li>Dysplastic nevi syndrome </li></ul><ul><li>Xeroderma pigmentosa </li></ul>
  7. 7. Diagnosis <ul><li>Symptoms: Pruritus </li></ul><ul><li>Signs: ABCDE </li></ul><ul><ul><li>A asymmetry of borders </li></ul></ul><ul><ul><li>B bleeding or crust </li></ul></ul><ul><ul><li>C change in color </li></ul></ul><ul><ul><li>D diameter >6mm </li></ul></ul><ul><ul><li>E elevation in flat area </li></ul></ul>
  8. 8. Biopsy <ul><li>Small and accessible lesions </li></ul><ul><ul><li>Excision with 1 cm margins in suspicious lesions </li></ul></ul><ul><li>Large lesions </li></ul><ul><ul><li>– Incisional or punch biopsy ? </li></ul></ul>
  9. 9. Pathological reporting <ul><li>Note history and surgery </li></ul><ul><li>Formalin fixation </li></ul><ul><li>PAD: </li></ul><ul><ul><li>Completely excised </li></ul></ul><ul><ul><li>Tumor thickness (Breslow) </li></ul></ul><ul><ul><li>Histogenetic type </li></ul></ul><ul><ul><li>Clark level of invasion </li></ul></ul><ul><ul><li>Ulceration, regression, mitotic activity </li></ul></ul>
  10. 10. Clark level of invasion <ul><li>Level 1: confined to the epidermis </li></ul><ul><li>Level 2: a few cells in the dermis </li></ul><ul><li>Level 3: cells in the papillary dermis </li></ul><ul><li>Level 4: invasion into the reticular dermis </li></ul><ul><li>Level 5: invasion into the fat </li></ul>
  11. 11. Breslow level of invasion <ul><li>Level 1: 0.0-0.75mm </li></ul><ul><li>Level 2: 0.76-1.50 mm </li></ul><ul><li>Level 3: 1.51-3.0 mm </li></ul><ul><li>Level 4: >3mm </li></ul>
  12. 12. Histogenetic type <ul><li>Superficial Spreading Melanoma (50-70%) </li></ul><ul><li>Nodular Melanoma (trunk) </li></ul><ul><li>Lentigo Maligna Melanoma (face) </li></ul><ul><li>Acral Lentiginous Melanoma (palmes and soles) </li></ul><ul><li>Amelanotic </li></ul>
  13. 31. Tests <ul><li>Thorough history and clinical examination </li></ul><ul><li>Noninvasive screening problematic </li></ul><ul><li>Pulmonary X-ray used as base-line information </li></ul><ul><li>Symptoms direct necessary examinations </li></ul>
  14. 32. ELM criteria: Results of 72 melanoma cases TnM: thin melanoma (<0.75 mm); TkM: thick melanoma (>0.75 mm) ELM criterion Present in 41 TnM n. (%) Present in 31 TkM n. (%) Pigment network 39 ( 95 ) 21 (68) Black dots 25 (61) 20 (64) Radial streaming 34 (83) 22 (71) Brown globules 32 (78) 22 (71) Diffuse gray-black blotches 25 (61) 20 (64) Gray-blue areas 10 (24) 29 ( 94 ) White scarlike areas 23 (56) 12 (39) Linear vascular pattern 6 (15) 6 (19) Dotted vascular pattern 1 (2) 14 ( 45 ) Structural asymmetry 31 (76) 27 (87)
  15. 34. Pigmented network + radial streaming Abnormal Vascolar pattern Thin Melanoma Thick Melanoma Gray, Blue, Shadow +
  16. 35. Melanoma Clinic Diagnosis Melanoma < 0,75 mm Excision (1 cm) Melanoma >0,75 mm Excision (2-3 cm) Lymph Node Biopsy Evaluation of Thickness by Epiluminescence Stereomicroscopic    
  17. 36. Classificazione TNM del Melanoma Stadio pT N M Ia Ib pT1 pT2 N0 M0 II pT3 N0 M0 IIIa IIIb pT4 Ogni pT N0 N1,N2 M0 IV Ogni pT Ogni N M1
  18. 37. pT Tumore primitivo <ul><li>pTx Il tumore primitivo non può essere definito </li></ul><ul><li>pT0 Non segni di tumore primitivo </li></ul><ul><li>pTis Melanoma in situ (livello I di Clark)(iperplasia melanocitica atipica, grave displasia melanocitica, non lesione melanocitica invasiva) </li></ul><ul><li>pT1 Tumore che invade il derma papillare con spessore < 0.75 mm (livello II di Clark) </li></ul><ul><li>pT2 Tumore con spessore compreso fra 0.75 ed 1.5 mm e/o con invasione dell’interfaccia fra derma papillare e derma reticolare (livello III di Clark) </li></ul><ul><li>pT3 Tumore con spessore >1.5 mm ma <4 mm e/o invasione del derma reticolare (livello IV di Clark) </li></ul><ul><li>pT3a Tumore con spessore compreso fra 1.5 e 3 mm </li></ul><ul><li>pT3b Tumore con spessore superiore a 3 mm ma inferiore a 4 mm </li></ul><ul><li>pT4 Tumore con spessore > a 4 mm e/o con invasione del sottocute (livello V di Clark) e/o con satellitosi entro 2 cm dal tumore primitivo </li></ul><ul><li>pT4a Tumore con spessore superiore a 4 mm e/o con invasione del sottocute </li></ul><ul><li>pT4b Satelliti entro 2 cm dal tumore primitivo </li></ul>
  19. 38. N Linfonodi regionali <ul><li>Nx I linfonodi regionali non possono essere definiti </li></ul><ul><li>No Non metastasi nei linfonodi regionali </li></ul><ul><li>N1 Metastasi di 3 cm o meno in qualunque linfonodo regionale </li></ul><ul><li>N2a,b Metastasi di dimensione massima superiore a 3 cm in qualunque linfonodo regionale (a) o metastasi in transit (b) (ossia interessante la cute od il sottocute a più di 2 cm dal tumore primitivo e non al di là dei linfonodi regionali) </li></ul><ul><li>N2c (a) + (b) </li></ul>
  20. 39. M Metastasi a distanza <ul><li>Mx La presenza di metastasi a distanza non può essere accertata </li></ul><ul><li>M0 Non metastasi a distanza </li></ul><ul><li>M1 Metastasi a distanza </li></ul><ul><li>M1a Metastasi nella cute o nel sottocute o nei linfonodi extra-regionali </li></ul><ul><li>M1b Metastasi viscerali </li></ul>
  21. 40. AJCC Staging System for Melanoma <ul><li>Stage I : Localized </li></ul><ul><ul><li>T1a or b: <1.0 mm, non-ulcerated or ulcerated </li></ul></ul><ul><ul><li>T2a: <2.0 mm, non-ulcerated </li></ul></ul><ul><li>Stage II: Localized </li></ul><ul><ul><li>T2b: <2.0 mm, ulcerated </li></ul></ul><ul><ul><li>T3a or b: <4.0 mm, non-ulcerated or ulcerated </li></ul></ul><ul><ul><li>T4a or b: >4.0 mm, non-ulcerated or ulcerated </li></ul></ul><ul><li>Stage III: Regional metastases </li></ul><ul><ul><li>N1: 1 N+ </li></ul></ul><ul><ul><li>N2: 2 to 3 N+ </li></ul></ul><ul><ul><li>N3: 4 N+ (or matted, in transit) </li></ul></ul><ul><li>Stage IV: Distant disease </li></ul><ul><ul><li>M1: distant skin, nodes </li></ul></ul><ul><ul><li>M2: Other, ↑LDH </li></ul></ul>
  22. 41. Local excision (based on thickness of tumour) <ul><li><0.75 mm: 1 cm margins </li></ul><ul><li>0.75 - 2mm: 2 cm margins </li></ul><ul><li>>2mm: 3 cm margins </li></ul>
  23. 42. Special locations <ul><li>The aim of excision is local control </li></ul><ul><li>Narrow excisional margins have not been proven fatal (?) </li></ul><ul><li>In special locations (ear, eyelids, digits) margins may be restricted for functional reasons </li></ul>
  24. 43. Regional lymph nodes <ul><li>Therapeutic lymphadenectomy of value (G öteborg – 27% 10-year survival) </li></ul><ul><li>Elective lymphadenectomy inconclusive </li></ul><ul><li>Sentinel lymph node biopsy complicated but successful in experienced hands </li></ul>
  25. 44. Sentinel biopsy concept <ul><li>To define the pathway from the melanoma site to the first draining lymph node by injecting dyes and radioactive tracers </li></ul><ul><li>If the node contains melanoma cells a proper lymphadenectomy is indicated </li></ul><ul><li>The rate at which this occurs is between 12% and 36% </li></ul>
  26. 45. Adjuvant therapy <ul><li>Interferon has been approved by the FDA in high risk melanomas </li></ul><ul><li>Toxic and expensive </li></ul><ul><li>Proven efficacy only in Stage II melanomas </li></ul>
  27. 46. 5 year Survival <ul><li><0.76 mm 96% </li></ul><ul><li>0.76-1.49 mm 90% </li></ul><ul><li>1.50-2.49 mm 80% </li></ul><ul><li>2.50-3.99 mm 73% </li></ul><ul><li>>4.00 mm 35% </li></ul>
  28. 47. Recurrences <ul><li>Regional Lymph nodes </li></ul><ul><ul><li>Radical removal </li></ul></ul><ul><ul><li>inteferon </li></ul></ul><ul><li>Local recurrence (within 2 cm of the scar) </li></ul><ul><ul><li>1 (-3) cm excision </li></ul></ul><ul><ul><li>Consider inteferon </li></ul></ul><ul><li>In transit metastasis </li></ul><ul><ul><li>Wide excision </li></ul></ul><ul><ul><li>Limb perfusion (melphalan and hyperthermia, or with tumor necrosis factor) </li></ul></ul>
  29. 48. Distant metastases <ul><li>Remote soft tissue or nodal metastases </li></ul><ul><li>Visceral metastases (lung, liver, brain, bone and gastrointestinal tract) </li></ul><ul><li>Curative surgical excision </li></ul><ul><li>Chemotherapy ? </li></ul><ul><li>Vaccines ? </li></ul>
  30. 49. Follow-up <ul><li>Goals </li></ul><ul><ul><li>To detect a second primary melanoma (3-5%) </li></ul></ul><ul><ul><li>To detect a local or regional recurrence </li></ul></ul><ul><ul><li>To detect distant metastases </li></ul></ul><ul><li>Intervals </li></ul><ul><ul><li>3 months for 5 years for lesions > 0.75 mm </li></ul></ul><ul><ul><li>6 months for 5 years for lesions < 0.75 mm </li></ul></ul><ul><ul><li>After 5 years once a year </li></ul></ul>
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×