This document discusses melanoma, a type of skin cancer that arises from pigment cells. It begins with an introduction and case presentation of a 51-year-old male diagnosed with melanoma on his foot. It then covers the history, epidemiology, risk factors, pathogenesis, classification, diagnosis, staging, differential diagnosis, treatment, complications, prognosis, prevention, and follow-up of melanoma. Local experience at the author's hospital is also discussed. The conclusion emphasizes the importance of early diagnosis and treatment for a good prognosis with this type of cancer.

1. MELANOMA
PLASTIC SURGERY UNIT.
BY
OKOYE C.

2. OUTLINE
• Introduction
• Case presentation
• Discussion
• Statement of Surgical Importance
• History
• Epidemiology
• Aetiology

3. OUTLINE
• Pathophysiology
• Classification
• Diagnosis
• Staging
• Differentials
• Treatment
• Complications

4. OUTLINE
• Prognosis
• Prevention
• Follow-up
• Local experience
• Conclusion
• References

5. Introduction
• Malignant Melanoma or Melanoma is a cancer arising from pigment
cells (melanocytes)
• Can affect skin, mucous membrane and the eye
• They often arise from existing mole
• When promptly diagnosed and treated, outcome is good but deadly if
diagnosis and treatment delayed

6. CASE PRESENTATION
• BI is a 51yr old male who presented via the plastic surgery clinic on account
of an ulcerated lesion on the plantar surface of the left foot, 4months
• It started as a dark mole 2years,6months prior to presentation; of gradual
onset, initially small in size then progressively increased in size, it ulcerated
4months prior to presentation.
• Nil similar lesions on other parts of his body
• Nil family history of similar lesions
• Nil features suggestive of metastasis
• He went to OLA hospital where lesion was excised with a histopathological
diagnosis of malignant melanoma. He was then referred to JUTH for expert
management
• Nil comorbidities

7. • O/E : Middle aged man, afebrile, not pale, not dehydrated, no
enlarged lymph nodes at the popliteal or groin area.
• Integumentary system: 3x3cm ulcer on the lateral aspect of the
(L)foot, slough and purulent discharge on the floor, irregular border,
granular base.
• Other sys; essentially normal
• Diagnosis; Malignant Melanoma Of The Plantar Surface Of The Left
Foot (T1b N0 M0)

8. • LDH, Left foot X-ray, CXR, Abdominal USS, PCV, E/U/Cr were
essentially normal.
• Surgical excision and STSG with intra-op finding of 3x3cm ulcerated
skin lesion on the lateral aspect of the (L)foot.
• Wound care
• He was discharged home on post operative day 6 to see in PLSOPD in
1/52.

11. Statement of surgical importance
• Melanoma constitute less than 5% of skin cancers yet it’s responsible
for 75% of deaths from skin cancers
• Adequate knowledge of the disease is important to ameliorate it’s toll
on patients

12. History
• First described in 1787 by John Hunter –“Cancerous fungous
excresence”
• 1812 Rene Laenec named it Melanosis
• 1820 William Norris described clinical course of Melanoma and
identified risk factors
• 1890s Sir Jonathan Hutchinson – subungual
• 1907 Wiliam Sampson Handley recommended surgical treatment,
selective lymphadenectomy

13. Epidemiology
• Even though all races can be affected, melanoma is largely a disease
of the whites.
• Increasing incidence in men more than any cancer
• However study in America between 2005 and 2014 showed
significant decrease in incidence among younger white adults (men
<45 and women <35 years)

14. Epidemiology
• 50% occur in patients >50 years
• Males, lifetime risk = 1:49 individuals
• Females, lifetime risk = 1:72 individuals
• Individuals living in hot climates

15. Epidemiology
• In LAUTEC, 1790 patients were managed for various forms of
malignancies
• Of these, 98 patients were histologically diagnosed as skin
malignancies (5.5%).
• 37 (37.8%), had malignant melanoma
• 22 (59.5%) were males and 15 (40.5%) females; M: F of 1.5:1).
• 58% involving the lower limbs

16. Aetiology
• Like most cancers, aetiology is not known but many risk factors
identified
• UV light exposure – all UV rays: A, B and C
• Phenotype: Fitzpatrick types I and II
• Age, sex, family history and prior history of melanoma

17. Risk factors
• Predisposing conditions:
– Atypical mole syndrome
– Dysplastic nevus
– Congenital nevus
– Melanoma in situ
– Xeroderma pigmentosum
– Lentigo maligna

18. Pathogenesis
• Development of malignant melanoma is multifactorial
• Genetic mutation and aberrations
• BRAF (V600E) mutation observed in half of all melanomas
– Observed more frequently in melanoma from sun exposed skin regions but
less so in acral and mucosal melanoma

19. Classification
• Superficial spreading
– Most common – 50 to 70%
– Usually arise from pre-existing nevus
– Long horizontal growth phase before vertical growth

20. Classification
• Nodular melanoma
– 15-30% of cases, aggressive, arises de novo typically
– M:F = 2:1, 1-2cm, dome shaped and resembles blood blister
– Keeps sharp demarcation due to lack of horizontal growth pattern
– 5% amelanotic

21. Classification
• Lentigo maligna
– 4-10% of all cases, least aggressive and clearly related to sun exposure
– Displays multiple shades of brown, radial growth phase of precursor lesion
(Hutchinson freckle)
– Transition to vertical growth heralds transformation to melanoma
– More common among females

22. Classification
• Acral lentiginous melanoma
– 2-8% of cases in whites but 35-60% of cases in nonwhites
– Affects palms, soles of feet, subungual and sun protected areas
– Linear pigmented streak in nail
– 3cm, flat with irregular border and multicolour shades
– Long radial growth, vertical growth increases metastatic risk

23. Other variants
• Desmoplastic melanoma
– 1% of all cases, perineural invasion, S-100 protein test positive on histology
but HMB-45 is negative.
– Regional lymph node spread frequent

24. Other Variants
• Amelanotic melanoma
– No pigment demonstrable by light microscope
– Diagnosed by immunohistochemical staining
– Usually diagnosed in vertical growth phase

25. Other Variants
• Noncutaneous melanoma
– 2% of all cases
– Mucosal melanoma
– Arises on mucosal surfaces
– Usually large at diagnosis
– Poor prognosis

26. Other Variants
• Ocular melanoma
– 2-5% of all cases
– Vision interference leads to early diagnosis
– Poor prognosis

27. Diagnosis
• History physical examination and investigation
• ABCDE

28. Diagnosis
• Biopsy
– Clinically suspicious lesions should be biopsied
– Excision – procedure of choice, 1-2mm margin
– Incisional /multiple punch– difficult areas
– Shave – avoid as it often misses deeper areas

29. Diagnosis
• Complete cutaneous examination+ lymph nodes
• If lymphadenopathy is found, USS or CT abdomen/ brain as indicated,
LDH to stage the disease

30. Staging
• Breslow
• Clark
• The thicker, the worst the prognosis

35. Differentials

36. Treatment
• Surgical excision
– Treatment of choice
– Wide local excision
– Margins: in situ = 0.5 cm, <1mm = 1cm, 1-4mm =2cm and >4cm = 2 to 3cm
– Should not include deep fascia
• Subungual – amputation proximal to DIP joint or interphalangeal joint
for thumb/big toe

37. Treatment
• Lymph nodes
– Sentinel lymph node biopsy (SLNB)
– Elective lymph node dissection (ELND)
– Therapeutic lymph node dissection

38. Treatment
• Sentinel lymph node biopsy
– A staging not therapeutic procedure
– Performed in conjunction with WLE of primary tumor
– Low complication and false negative rate, skip metastasis reported in 0-2%

39. Treatment
• SLNB
– Indication
• Stage IB and II
• 0.76-1mm with ulceration or mitotic rate ≥1 per mm2, or >1.0mm thick
• If negative no need for ELND

40. Treatment
• Elective lymph node dissection
– Lymph node dissection in clinically node negative
– High risk individuals
• Therapeutic lymph node dissection
– Dissection in clinically positive node
– SLNB positive patients

41. Treatment
• Radiotherapy
– Rarely indicated for primary tumor
– As adjuvant for regional or high risk disease
– For poor surgical candidates

42. Treatment
• Chemotherapy
– Dacarbazine (DTIC) as single agent or in combination
– For late disease, response rate not so good in general
• Immunotherapy
– Ipilimumab – a monoclonal antibody directed to the receptor CTLA-4
– Interferon alpha-2b
– Interleukin-2 has been approved for stage IV disease

43. Treatment
• Limb perfusion
– For locoregional disease

44. Complications
• Recurrence
• Lymphedema
• Limb ischaemia from limb perfusion

45. Prognosis
• Largely depends on stage of disease
– Stage IV disease is fatal
• Early presentation and prompt treatment gives better prognosis

46. Prevention
• Avoidance of direct sun exposure in patients with sensitive skin
• Prompt diagnosis and treatment of premalignant lesions

47. Follow-up
• Recurrence more common in first 3 years (approx 81%)
• 3 monthly for 3 years then 6 monthly for 2years then yearly after –
high risk patients
• 6 monthly for 3 years then yearly afterwards for low risk patients
• Even after 10 years patient cannot be declared cured as reccurence
after 10 years have been documented

48. Local experience
• We are seeing an array of presentations: early and late
• Acral commonly, superficial spreading
• Mostly in extremities
• HIV patients presenting with the disease
• For early, excision usually suffice but the late usually succumb to their
disease

49. Conclusion
• Melanoma, though rarer than others, is a fatal skin malignancy
• Early diagnosis and prompt treatment proffers excellent outcome
• When seen early, best treatment is surgery with adequate margin

50. Reference
• Daniel KC, Keith MB. Dermatology for plastic surgeons II-cutaneous malignancies.
In: Aston SJ, Beasley RW,Thorne CHM, editors. Grabb & Smith’s plastic surgery.
7th edition. China: Lippincott-Raven Publishers; 2014;118-124.
• Daniel ML, Smita RR, Dawn DW. Basal cell carcinoma, squamous cell carcinoma
and melanoma. In: Jeffrey EJ, editor. Essentials of plastic surgery. 2nd edition. US:
CRC press, 2014.
• RobertGA. In: Selected reading in plastic surgery. Skin tumours II: melanoma.
Dallas. Baylor; 2000; 9 (6):44p.
• Kricker A, Amstrong BK, English DR. Sun exposure and non- melanocytic skin
cancer. Cancer Causes Control. 1994; 5(4):367-392.
• Ochicha O, Edino ST, Mohammed AZ and Umar AB. Dermatological malignancies
in Kano, Northern Nigeria: A histopathological review. Annals of African Medicine.
2004; 3(4):188-191.