For surgical residents presentation

1. Malignant Melanoma
By
Dr. Olofin K.E
Registrar surgery Dept WDH

2. Outline
• Introduction
• Epidemiology
• Pathology
• Risk factors
• Clinical and pathologic staging
• Clinical presentation
• Management
• Prognosis
• Conclusion
• References

3. Introduction
• Malignant melanoma is the most deadly form of skin cancer,
• It has the highest mortality rate of all dermatological cancers
• One of the most common cancer in young adults

4. Epidemiology
• The incidence has been steadily increasing over the past 50 years
(currently 20 in 100,000 people),
• It is the fifth most common malignancy in men and the seventh in
women, and 1 in 52 people will be diagnosed with melanoma in their
lifetime.
• Although melanoma accounts for less than 5% of all skin cancer cases,
it results in greater than 75% of skin cancer deaths.

5. • Median age 55 years for both sexes
• About the same number in both sexes
• In males the highest incidence and fastest increase are in trunk
melanomas
• In females the highest incidence and fastest increase are in
melanomas of the lower leg

6. Pathology
• Melanoma is cancer of
the melanocytes.
• Melanocytes are located
in the Stratum Basale
and produce melanin.

7. • When skin is exposed to sunlight, melanocytes produce more
pigment, causing the skin to tan.
• Sometimes, clusters of melanocytes form noncancerous (benign)
growths called moles.
• Moles can be either flat or raised, round or oval, and are smaller than
a pencil eraser.
• Generally harmless, but can become cancerous

10. Risk Factors
• Family history of melanoma (10%)
• Dysplastic nevi (noncancerous, but unusual- looking moles)
• Previous melanoma (5%)
• Many nevi (ordinary moles): more than 50
• Severe, blistering sunburns
• Freckling tendency
• Fair skin
• Excessive use of tanning beds
• Genetic predisposition

11. • It is important to note that while intense sun damage is very strongly
associated with melanoma,
• It is not necessarily required for malignant transformation, as a
significant number of lesions arise in relatively sun protected areas
(soles of feet, anus, and vagina)

12. Clinical presentation
• Can appear suddenly as a new mole or develop slowly in or near an
existing mole.
• In men, melanomas are often found between the shoulders and hips,
or the head and neck area.
• In women, melanoma often develops on the lower legs as well as
between the shoulders and hips.
• It may also appear under the fingernails or toenails or on the palms or
soles

13. ABCDE of melanoma
• A is for Asymmetry: – One half of a mole or birthmark does not match the
other.
• B is for Border: – The edges are irregular, ragged, notched, or blurred.
• C is for Color: – The color is not the same all over and may include shades
of brown or black, or sometimes with patches of pink, red, white, or blue.
• D is for Diameter: – The spot is larger than 6 millimeters across (about ¼
inch – the size of a pencil eraser), although melanomas can sometimes be
smaller than this.
• E is for Evolving/elevated: – The mole is changing in size, shape, or color.

14. Clinical and pathologic staging
Histogenetic type
• Superficial Spreading Melanoma (50-70%)
• Nodular Melanoma (trunk)
• Lentigo Maligna Melanoma (face)
• Acral Lentiginous Melanoma (palmes and soles)
• Amelanotic

15. • Superficial spreading
melanoma presents as flat or
slightly elevated lesion with
variegate pigmentation
• most commonly occurring on
the trunk in men and the
legs in women, in patients
aged 30 to SO years.

16. Nodular melanoma
• Second most common type (15%)
• Vertical growth pattern
• Worst prognosis based on a higher
average tumor thickness.
• frequently affecting the legs or trunk.

17. Lentigo maligna melanoma
• Sun-damaged skin
• Flat,darkly pigmented
• lesion with irregular
• borders and a history of slow
development

18. Acral lentiginous melanoma
• Seen in blacks
• Commonly occurs on the palms
of the hand, sole of the feet, or
beneath the nail plate
(subungual)
• presents at a more advanced
stage with an aggressive course
compared with the other
subtypes.

19. Amelanotic Melanoma
• Uncommon
• Difficult to diagnosis
• Lacks pigmentation
• presents as an unremarkable plaque or nodule
• can easily be misdiagnosed at an early stage.

20. Stage (Clark’s level or Breslow Depth)

21. Clark Classification (Level of Invasion)
• Level I: Lesions involving only the epidermis (in situ melanoma); not
an invasive lesion.
• Level II: Invasion of the papillary dermis but does not reach the
papillary-reticular dermal interface.
• Level III: Invasion fills and expands the papillary dermis but does not
penetrate the reticular dermis

22. • Level IV: Invasion into the reticular dermis but not into the
subcutaneous tissue.
• Level V: Invasion through the reticular dermis into the subcutaneous
tissue

23. Breslow level of invasion
• Level 1: 0.0-0.75mm
• Level 2: 0.76-1.50 mm
• Level 3: 1.51-3.0 mm
• Level 4: >3mm

28. Management
History
Examination : All patients diagnosed with cutaneous melanoma undergo a
thorough skin assessment and clinical evaluation.
Investigation
• Biopsy
• FBC, E/U/Cr, LFT
• Chest X-ray, Abdominopelvic USS, CT scanning
• MRI of the brain, and bone scan.

29. Treatment
Excision is the mainstay of treatment
• Early stages: – Wide local excision
• More advanced: – Wide local excision plus sentinel node biopsy,
• Based on the pathology
• Lympadnectomy
• observation
• interferon
• Metastatic:
• Clinical trial
• Radiation and systemic therapy

31. Elective lymph node dissection (ELND)
• Use of prophylactic dissection (clinically negative nodes) is
controversial
• No prospective, randomized studies have demonstrated that elective
LN dissection improves survival in patients with intermediate
thickness melanomas

32. • Dissection should be complete
• Groin dissection
• Deep (iliac) nodes must be removed along with the superficial (inguinal)
nodes
• Axillary dissection
• All levels I, II, III should be removed
• Head and Neck
• Superficial parotidectomy to remove parotid nodes

33. Sentinel biopsy concept
• To define the pathway from the melanoma site to the first draining
lymph node by injecting dyes and radioactive tracers
• If the node contains melanoma cells a proper lymphadenectomy is
indicated
• The rate at which this occurs is between 12% and 36%

35. Complications
• Wound seroma
• Cellulitis
• lymphedema

36. Radiation
• Used in some cases
• High doses
• Not so useful

37. Adjuvant therapy
Chemotherapy
• Dacarbazine is drug of choice
• Other drugs
• Cisplatine
• Paclitaxel
• Docetaxel
• Temozolomide

38. Immunotherapy
• Interlukin IL-2 and Interferon on high doses
• Interferon has been approved by the FDA in high risk melanomas
• Toxic and expensive
• Proven efficacy only in Stage II melanomas
• BCG

39. • Monoclonal antibodies – Ipilmumab
• Tumour vaccine
– Polyvalent melanoma vaccine (Canvaxin)
– Allogenic melanoma cell lysate (Melacin)
– Detoxified endotoxin/myco bacterial cell wall skeleton (DETOX)
– Gp 100 DNA vaccine
– GM-CSF 2nd generation oncolytic herpes virus vaccine

40. Targeted therapies
• BRAF Inhibitor – PLX4032(vemurafenib)
• KIT Inhibitor – Imantinib mesylate

41. Follow up
• Goals
• To detect a second primary melanoma (3-5%)
• To detect a local or regional recurrence
• To detect distant metastases
• Intervals
• 3 months for 5 years for lesions > 0.75 mm
• 6 months for 5 years for lesions < 0.75 mm
• After 5 years once a year

42. Prognosis
• Based on clinical and pathologic features
Clinical features
• Sex: F >M
• Age: <60 better
• Site of tumor: Scalp,face,feet, trunk have poorer prognosis
• Pre-existing nervus
• Skin colour

43. • Pathological indicators
• Tumour thickness( Breslow stage)
• Ulceration
• Nodular, acral lentiginous and genital melanomas
• Level on invasion ( clarks level)
• Size of tumour:< 2cm good prognosis
• Type of melanoma: leningo maligna best, nodular worst prognosis

44. SURVIVAL RATES FOR MALIGNANT MELANOMA BY STAGE
• STAGE •5Y (%) •1OY(%)
Stage lA 97 95
Stage 1B 92 86
Stage IIA 81 67
Stage II B 70 57
Stage IIC 53 40
Stage IIIA 78 59
Stage III B 59 43
Stage IIIC 40 24
Stage IV 15 10

45. Conclusion
• Early detection is very important in curing malignant melanoma
unfortunately patients in our environment present late believing
there lesion is not medical
• Even those who present early still believe excision is not a cure which
has made it a serious public health problem.
• Public enlightenment will increase awareness of the disease and its
prevention
• This will lead to a decrease incidence rate, morbidity and mortality
while increasing prognosis.

47. References
• Grabb And Smith's Plastic Surgery Seventh Edition
• Principles and practice of surgery including pathology in the tropics
4th edition
• Edge SB, Byrd DR, Compton CC, et al., eels. AJCC Cancer Staging
manual. 7th edn. New York, NY: Springer; 2010.

48. Thank you