melanoma.pptx

MALIGNANT MELANOMA
Dr Malinga Gunarathne
Registrar in surgery
Ward 11/12
06/08/2022 Saturday forum

skin lesions
Benign
1. Seborrheic keratosis
2. Papillary warts
3. Freckles
4. Lentigo
5. Moles/naevi
Premalignant
1. Actin keratosis
2. Leukoplakia
3. Erythroplakia
Malignant
1. Squamous cell ca
2. Basal cell ca
3. Malignant melanoma

Melanocytes
• are dendritic cells
• neural crest origin
• located in the basal epidermis.
• Synthesize melanin, a brown-black pigment,
• transferred via membrane processes to the keratinocytes
• Melanin provides protection against ultraviolet radiation.

EPIDEMIOLOGY
• Among white skin people
• Common – Australia, New Zealand (Taranaki in New Zealand, a country with a predominantly white-
skinned, immigrant population, currently reports the highest (and rising) incidence per capita)
• Primary malignant melanomas can arise as,
new lesions (60%)
pre-existing melanocytic naevi
• 1.6% of all malignancy worldwide
• less than 5% of skin malignancy,
• Responsible for over 75% of skin malignancy-related deaths
• It is the commonest cancer in young adults (20–39 years)
• 5% of all patients with MM will develop a second primary melanoma
• 7% of MM presents as occult metastasis from an unknown primary.

Risk factors
• Sun exposure-UVR
• White skin
• Genetic-
Family history
cancer syndromes-
Familial atypical multiple mole and melanoma syndrome (FAMMM)
Xeroderma pigmentosum
• Immune deficiency (increases the incidence by 20-30 fold)

Spread – local
• Malignant change occurs in the melanocytes in the basal epidermis
• 2 phases,
 horizontal growth phase
 cells spread along the dermo-epidermal junction
Malignant melanoma in situ
atypical melanocytes are limited to the dermo-epidermal junction(Clark level I)
Microinvasive melanoma
They have microscopic extensions in to papillary dermis- Clark level II
 vertical growth phase,
Acquire all the features of malignancies( invasion & metastasis) - the dermis is invaded & +/- metastasis lesions
Clark level III- V

Spread Loco-regional
• Spread along lymphatics – regional LN groups
Satellite lesions
• A lesion with in 2 cm of the primary lesion
detected clinically(macro) or microscopically (micro)
In transit lesions
• metastases with in regional dermal and subdermal lymphatics more than 2cm
from the primary, but not beyond the regional nodal basin

Spread -Systemic
• No organ is spared

The Clark Scale has five levels:
•Level 1: Melanoma is confined to the epidermis (the outer layer of the skin).
•Level 2: Melanoma has invaded the papillary dermis (the outermost layer of the dermis, the next layer of skin).
•Level 3: Melanoma has invaded throughout the papillary dermis and is touching on the next, deeper layer of the dermis.
•Level 4: Melanoma has invaded this next deeper layer, the reticular dermis.
•Level 5: Melanoma has now invaded the fat under the dermis.

• Why the depth is mattered?
• The greater the depth of invasion, the greater is the metastatic
potential of the tumour

Clinical features
ABCDE criteria
increase the public’s awareness of melanomas
A. Asymmetry,
B. Border irregularity,
C. Color variation
D. Diameter > 6 mm
E. Evolution.
• new mole that appeared after the onset of puberty
• mole which has lost its symmetry, itchy and bleeding, is growing, especially under the nail

Revised Glasgow seven-point
checklist
• Major criteria
◦ Change in size or new lesion
◦ Change in shape
◦ Change in color
• Minor criteria
◦ Diameter >7mm
◦ Inflammation
◦ Crusting or bleeding
◦ Sensory change

Sub types
1. superficial spreading melanoma
2. Nodular melanoma
3. lentigo maligna melanoma
4. acral lentiginous melanoma
desmoplastic melanoma
amelanocytic melanoma
mucous membranes (e.g. gut,oral cavity, eye and nasal paranasal sinuses).

superficial spreading melanoma
• Most common -70%
• Usually –from pre-existing naevus
Nodular melanoma
• 15% of all MM and tends to be more aggressive than SSM
• common in men than women
• often presenting in middle age
• on the trunk, head or neck
• blue/black papules

lentigo maligna melanoma
• 5% and 10%
• slow-growing
• face, neck or hands
• Common in elderly
acral lentiginous melanoma
• Rare 2–8%
• (Asian population - 35–60%)
• soles of feet and palms of hands
• 25% are amelanotic - mimic a fungal infection or pyogenic granuloma.

Mucosal melanoma
• a rare variant
• sites- oral cavity,nasal cvity,sinuses, anorectum and
vulvovaginal regions.
• Very poor prognosis
• Etiology – UVR??

Investigations
For local lesion???
• Excision biopsy- WLE(diagnostic & therapeutic )
• (Incision biopsy- Face)
• Dermoscopic examination
For systemic disease
• FNAC- LNs
• Sentinel node biopsy
• CT/MRI
• LDH
Immunohistochemistry
Helpful in difficult diagnoses
S-100, MART-1, HMB-45, SOX-10

Staging

Management – primary lesion
• The only curative treatment for melanoma is surgery
• suspected lesion -excision biopsy with a 2-mm margin
• Then, Asses Breslow thickness of the specimen
• Then, wider local excision of the excision biopsy scar is carried out

Management- regional
• radical lymph node dissection.
Nodal + disease
(seroma)
• regional chemotherapy with, melphalan & radiotherapy
for,
progressive recurrent metastatic disease
not responding to surgery
deeper metastatic disease
Hyperthermic isolated limb perfusion (ILP)
Normothermic isolated limb infusion (ILI)

Hyperthermic isolated limb perfusion (ILP)
• A tourniquet is applied around the root of the extremity to occlude the superficial veins
• Surgically separates the vascular inflow and outflow of the affected limb from the rest of the
body(upper limb- axillary vessels and lower limbs external iliac vessels)
• Vessels are connected to inflow and outflow lines of an extracorporeal bypass circuit
• Then the limb is subjected to mild hyperthermia (40ºC) - vasodilatation that improves anti tumor
effect of the drug melphalan
• Allows high concentration of drugs to circulated locally without exposing the body to the same
level of toxicity
• Since liver and kidney are excluded, high concentrations of the drug remains in the limb
Normothermic isolated limb infusion (ILI)
• Less invasive
• Short duration
• Slow flow rate

• Electrochemotherapy (ECT)
• Short electrical pulses are applied
• De stabilizes the cell membrane
• Increases permeability for cytotoxic drugs – increases potency of
drugs

Management- systemic -ADJUVANT THERAPY
• Cyto-toxic drugs/ target therapy-
1. BRAF- vemurafenib ,dabrafenib and trametinib
2. KIT inhibitors-imatinib

Prognosis
• Breslow thickness
• higher the mitotic index
• TNM staging (Once regional nodes are clinically involved, 70–85% of patients will have occult
distant metastases)

summary
• Most serious type of skin malignancy
• ABCD criteria with public awareness
• Surgery - best
• Advanced disease –associated with high mortality
• Help of new treatment options?

45 yr old mae
Previously healthy
Lesion at big toe x 2yrs
Histology- acral lentiginous melanoma

references
1. NCCN Guidelines Version 3.2020 Cutaneous Melanoma Continue NCCN Guidelines Panel Disclosures
2. The management of malignant skin cancers
3. Melanoma and other skin cancers: a guide for medical practitioners
4. Baily & love

Feed backs
Add on- desmoplastic melanoma &amelanocytic melanoma
Indications for sentinel LN Bx—read NCCN

melanoma.pptx

Recommended

Recommended

More Related Content

Similar to melanoma.pptx

Similar to melanoma.pptx (20)

Recently uploaded

Recently uploaded (20)

melanoma.pptx

Editor's Notes