Carrozzo Anna Maria. Clinica e Diagnostica del Melanoma. ASMaD 2012

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Carrozzo Anna Maria. Clinica e Diagnostica del Melanoma. ASMaD 2012

  1. 1. ANNA MARIA CARROZZO
  2. 2. ll melanoma è un tumore maligno cheorigina dai melanociti della cute e delle mucose, dai melanociti che costituiscono i nevie, molto più raramente, dai melanociti posti in sedi extracutanee(occhio, orecchio interno, meningi, mesenchima viscerale).
  3. 3.  CRITERI CLINICI X IL RICONOSCIMENTOA asimmetriaB bordi irregolariC colori multipliD dimensioniE evoluzione intesa come cambiamento
  4. 4.  LENTIGO MALIGNA-MELANOMA: 10% SUPERFICIAL SPREADING MELANOMA: 70% MELANOMA NODULARE (NODULARE-ACROMICO): 15% ACRAL LENTIGINOUS MELANOMA:5% Varianti istologiche Animal Melanoma Melanoma desmoplastico
  5. 5. LENTIGO MALIGNA o MELANOSI DI DUBREUILH LENTIGO MALIGNA-MELANOMA
  6. 6. SSM
  7. 7. SEDI PARTICOLARIMELANOSI DELLE MUCOSE
  8. 8. MELANOMA NODULAREMELANOMA NODULARE ACROMICO
  9. 9. ALM
  10. 10. FATTORI PROGNOSTICI Breslow-Clark n° Mitosi x campo Ulcerazione
  11. 11. CLARK Livello I: Melanoma in situ: il tumore ènellepidermide al di sopra di una lamina basale intatta; Livello II: il tumore invade il derma papillare;Livello III: il tumore arriva fino allinterfaccia tra derma papillare e derma reticolare, senza infiltrare questultimo; Livello IV: il tumore invade il derma reticolare; Livello V: il tumore invade il tessuto sottocutaneo.
  12. 12. Breslow Sopravvivenza a 10 anni_< 1mm 91%1,01-2,0mm 78%2,01-4,0mm 62%> 4mm 38%
  13. 13. Eleven Independent Clinicopathologic Prognostic Markers for Cutaneous Melanoma  Age at Diagnosis  Gender  Growth phase (radial vs vertical)  Thickness  Level of invasion  Presence of ulceration Presence and density of tumor infiltrating lymphocytes  Regression  Presence of microsatellites  Presence of vascular and lymphatic invasion  Presence and quantity of mitotic figures
  14. 14. PRECURSORI MELANOMA Cute normale Nevi acquisiti Nevi congeniti Nevi displastici
  15. 15. La dermoscopia (o microscopia aepiluminiscenza) é una tecnicadiagnostica per esaminare in vivo lesionicutanee, ingrandite di 10-20 volte. Sitratta di unapparecchiatura che utilizza:olio che, applicato sulla lesione rende ilderma più trasparente; un obiettivo, cheposto a diretto contatto con la lesionetramite lolio potenzia lesame in vivodelle strutture della giunzione dermo-epidermica; una sorgente di luce e unalente dingrandimento.
  16. 16. Melanoma in situ
  17. 17. Melanoma in situ
  18. 18. Più recentemente, sono stati studiati sistemi digitali di diagnostica per immagini: epiluminiscenza.
  19. 19. 22-10-2007 dm. 4,00x2,4mm dm 4,1x2,5mm 01-04-2008 50X 50X 06-10-2008 dm. 4,2x2,5mm 22-06-2009 50X 50X dm.4,1x2,4mm
  20. 20. Proliferazione melanocitaria atipica Intraepidermica suggestiva per formainiziale di melanoma in situ associata ad intensoinfiltrato infiammatorio del derma papillare- reticolare Margini di escissione chirurgica indenni
  21. 21. B A
  22. 22. ATYPICAL MOLE SYNDROME AND DYSPLASTIC NEVI: IDENTIFICATION OF POPULATIONS AT RISK FOR DEVELOPING MELANOMAJ.H. Silva, B.C.Soares de Sa et Al. CLINICS 2011 MarchIn 1820, Norris described what is currently considered in a family predisposed to melanoma.In 1978 Clark reported an increase incidence of cutaneous melanoma in families with multiple melanocytic lesions, introducing the melanoma tumor progression model from melanocytic nevi, and used the term B_Kmole syndrome, from the initials of the patients surnames. Now the terms AMS,Dysplastic Nevus Syndrome and Familial Atypical Multiple-Mole Syndrome (FAMMS) have been employed.In 1985, Elder extended the theory of nevus-melanoma for sporadic dysplastic nevi as a possible precursor of sporadic melanoma
  23. 23. 1984-2008 A.B.Ackerman"The perplexing story of the dysplastic nevus and the dysplastic nevus syndrome can be comprehended only in the context of understanding the consistent lack of a repeatable definition of dysplasia and the persistent failure to provide reliable criteria for clinical and histopathologic diagnosis of dysplastic nevus. As a consequence of these rickety underpinnings, it was inevitable that the edifice would collapse, and it did in less than 15 years. The epitaph for dysplastic nevus was written in 1992, and that was published in the Journal of the American Medical Association in 1992. In that report, the panel stated that the term dysplastic nevus had outlived its usefulness and should be abandoned. We concur and advise further that the concepts of dysplasia, dysplastic melanocytes, dysplastic nevus, and the dysplastic nevus syndrome not only be abandoned now, but that they also not be supplanted by equally opaque notions, such as cytologic and architectural atypia, nevus with histologic dysplasia, clinically atypical mole, and atypical mole syndrome.Resolving Quandaries in Dermatology, Pathology and Dermatopathology. pp 88. Promethean Medical Press/Waverly, 1995.
  24. 24. Several studies have shown that the presence of dysplastic nevi considerably increases the risk of developingmelanoma, which demonstrates that these lesions, aside from being precursors to disease are also important risk markers
  25. 25.  Atypical moles differ from common acquired melanocytic nevi in several respects, including diameter and lack of pigment uniformity. Confusion exists because some atypical moles cannot be clinically distinguished from melanoma. The clinical and histologic appearances of atypical moles occurring in a familial setting appear to overlap with sporadically occurring atypical moles. The US National Institutes of Health Consensus Conference on the diagnosis and treatment of early melanoma defined a syndrome of familial atypical mole and melanoma (FAMM). The criteria for FAMM syndrome are as follows: The occurrence of malignant melanoma in 1 or more first- or second-degree relatives The presence of numerous (often >50) melanocytic nevi, some of which are clinically atypical Many of the associated nevi showing certain histologic features (see Histologic Findings)
  26. 26. Dysplastic nevus (atypical nevus)Gisele Gargantini Rezze, Alexandre Leon, Joao DupratAbstract: Atypical nevum (dysplastic) is considered an important factor associated with increased risk ofdeveloping cutaneous melanoma. It is believed that atypical nevi are precursor lesions ofcutaneousmelanoma.They may be present in patients with multiple melanocytic nevi (atypical nevus syndrome) or isolatedand in small numbers in a non-familial context. The disease usually begins at puberty and predominatesin young people. It has a predilection for sun-exposed areas, especially the trunk. The major challengein relation to atypical nevi lies in the controversy of defining its nomenclature, clinical diagnosis, dermoscopiccriteria, histopathological diagnosis and molecular aspects. This review aims at bringing knowledge,facilitating comprehension and clarifying doubts about atypical nevus. An Bras Dermatol. 2010;85(6):863-71.
  27. 27. Ing.30X dm.5,7x4,8 Ing.30X dm.8,4x6,4 09-03-2010, reg. 09-03-2010, reg. scapolare sternale, nevo dx, nevo displastico displatico
  28. 28. dm.4,8x4,00mm dm.5,00x4,3mmIng.30X Ing.30X Gomito sx 03-05-2010 22-11-2010 SSM a cellule fusate ed epitelioidi,in fase di crescita radiale infiltrante il derma papillare II Clark, Breslw.0,22mm
  29. 29. dm. 11,2x8,2mm 15-02-2011, Interscapolare paravert. Dx, Melanoma in situ, IClark 15-02-2011 sottoscapolaresx 20X Nevo displastico con focali aree di trasformazione melanomatosa 20X in situ, IClark dm. 8,00x6,5mm
  30. 30. Ing.30X 09-02-2010 Melanoma a diffusione superficiale della pianta piede sx, Clark:II, Breslow:0,3 mm. Ing.30X 30X dm.3,8x3,1mm ANAMNESI:dal febbraio 2004 ad oggi: 1)Nevo melanocitico giunzionale displastico 2)Melanoma della gamba dx insorto su nevo dm 4,8x4,00 23-11-2010 Clark:III; Breslow 0,5mm 3) vari nevi composti26-11-2009 Ing.30X dm:4,4x4,2 10-04-2012: Nevo Composto dm 4,7x4,4
  31. 31. Ing. 15X Melanoma infiltrante il 28-11-2008 derma papillare, II Clark, Breslow 0,45mm Ing.20Xdm. 10,9x6,6mm 24-04-2009 dm. 7,3x6,2mm Nevo melanocitico giunzionale con aspetti displastici
  32. 32. dm. 3,1x2,9mm Ing.30X dm. 3,2x3,0mm Ing.30X12-01-2009 05-05-2009 dm. 3,4x3,2 mm Ing.30X reg. tibiale ant.dx. SSM infiltrante il derma papillare, II Clark, Breslo 28-01-2010 w 0,15mm
  33. 33. dm. 3,7x3,3mm 19-07-2007 , ginocchio interno sx ,Ing. 30X 22-05-2008 SSM, in fase di crescita radiale II Clark, 0,25 Breslow Ing. 30X dm.4,00x3,3mm
  34. 34. dm.2,2x2,00mm 24-09-2010 caviglia sx dm.2,7x2,6mmIng. 50X SSM in fase di crescita radiale a cellule epitelioidi, infiltrante il derma papillare II Clark, Breslow : 0,4mm 28-01-2011 Ing. 50X
  35. 35. VivaScope® Technology(Reflectance Model) Detector Pinhole Focusing Lens Laser Beamsplitter Scanning Optics Quarter Wave Plate Objective Lens Windo w Tissue Sample
  36. 36. VivaCamTM Macroscopic Camera OptionClinical Photographof a Lesion 3mm x 3mm VivaBlockTM 10mm x 10mm VivaCamTM Image
  37. 37. K. Busam, C. Charles, A. Marghoob, MSKCCImage taken at the papillary dermis of the biopsy-proven nevus component (A) of previousnevus shown in the previous slide. Notice the organized nests of nevomelanocytes within thesuperficial dermis, consistent with a benign lesion. 500 µm field of view.
  38. 38. GRAZIE
  39. 39. ANIMAL MELANOMA: di recente codifica. E’ unMelanoma che sintetizza pigmento. E’ una varianteistopatologica rara, così chiamato per la prominenteproduzione di melanina, che appare simile ad unavariante di melanoma osservata nei cavalli grigiMELANOMA DESMOPLASTICO: forma rara diMelanoma, caratterizzato dalla tendenza ad infiltrare ivasi sanguigni, a diffondersi per invasioneperineurale e per l’alta frequenza con la qualerecidiva localmente.

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