A 36-year-old woman presents with a dark, irregular pigmented patch on her calf that has increased in size over 4 months. She has a history of sun exposure including tanning bed use and a family history of melanoma. Physical examination finds multiple normal moles but the calf lesion is asymmetrical with irregular borders and color. Melanoma is a malignancy of melanocytes that can metastasize to lymph nodes and distant organs. Risk factors include excessive sun exposure, many moles, and family history. Diagnosis involves biopsy with histology and staging includes tumor thickness. Treatment depends on stage but may include surgery, radiation, chemotherapy, or targeted therapy. Prognosis depends on stage, with early stage having

1. PDT:
melanoma
Ibrahim Albarakati
Suprvised by : Dr. Tawfeeq Alyafi

2. Outlines
• Case scenario
• Definition and epidimiology
• Pathophysiology
• Risk factors
• Classification and clinical presentation
• Diagnostic approach
• Management
• Prognsis and prevention

3. History
• A 36-year-old fair-skinned woman presents with a dark, irregular,
pigmented patch that she noted 4 months ago on the right posterior
calf. It has gradually increased in size. She reports approximately 6
sunburns in the past and has been using tanning beds several times
yearly for the past few years. Family history is positive for melanoma
in her uncle.

4. Physical Examination
• On physical examination, approximately 15 normal-appearing naevi,
ranging in size from 3 mm to 5 mm, with symmetry, uniform brown
coloration, and regular borders are noted elsewhere on the torso and
extremities. The pigmented lesion on the right calf is asymmetrical
along 2 axes, measures 1 cm x 0.8 cm, is deeply pigmented with
several shades of brown, and has a jagged border. The popliteal nodes
are not clinically palpable.

5. Definition
• It is a malignany tumor of epidermal melanocyte that can be
metastsised.

6. Epidmiology
• Skin cancer is the most common malignancy in fair-skinned
population
• The most common skin cancer is basal cell cancenima, However the
most common skin cancer related death is accretied to melanoma
• Melanoma accounts for 1% to 2% of all malignant tumors
• In US, it is the fifth most common cancer among males and seventh
among femfales
• More common in women and unusual in child

7. Epidmiology
• Occurs most commonly between ages 40 and 50
• The incindence in younger age groups is increasing because of
increased sun expusre or possibly, decrease in the ozone layer
• UVR the main environmental risk factor for skin cancer
• More common in high ambient sun exposure such as Australasia
• Also, it increases if someone moves to such a country at a young age,
less than 10

8. Pathophysiology
• The disease arises from melanocytes, cells that syntheszie the
pigment melanin.
• Melanocyte can spread to lymphatics and vascular system and
metasitise to lymph nodes, skin, subcutanous (59%), lungs(36%),
liver(20%), and CNS(20%), bone(17%), GI tract(7%)
• It is thought that the disease can happened via environmental and
genetic predispoition factors

9. Envirnmental
• Recent meta analysis have confirmed that there is association
between sunbed use and skin cancer, particularly when it commences
in early life

10. Genitically
• Some people may inherit mutated genes from parents
• Mutation in genes coding for p16(CDKN2A) tumor suppersor genes
can increase life time risk of melanoma up to 50%.

11. Risk factors
• Excessive exposure to sunlight
• Increased nevi >50
• Tendecy to freckle from sun
• Hormonal factors such as pregnancy
• A family hisotry of melanoma
• A Personal history from melanoma
• Red hair, fair skin, blue eyes, suscbiility to sunburn, and celtic or
scandnavian ancestry( melanoma is rare in blacks)

12. Classification and clinical presentation
• Skin Cancer :
• NMSC
• BCC
• SCC
• Melanoma
• Melanoma without metastatic potenial
• Melanoma in situ
• Lintigo maligna
• Melanoma with invasive potenial
• Superficial spreading melanoma
• Nodular melanoma
• Acral lenitinous or palmoplantar melanoma
• Subungual melanoma
• Lentigo maligna melanoma

13. Classification and clinical presentation
• Can occur at any age and any site and in either sex
• It typically affects the legs in females and back in males
• It is rare before puberty

14. Superficial spreading melanoma
• Most common type in Caucasians (60-70%)
• Any site but preference torso in men and legs in women
• Most common in ages 30-50 years
• Slowly enlarging, macular pigmented lesions, with increasing
irregularity in shape and pigmentation, this superficial radial growth
can be up to 2 years
• After that, it will be palpable and indicative of vertical growth phase
invasive disease in the dermis
• Now it can invades lymphatics and vessels and become metastatic

15. Superficial spreading melanoma

16. Nodular melanoma
• Second most common (15-30%)
• Most common in fifth and sixth decades
• In men
• And on the trunk
• Increased maortality from melanoma in men can be accounted to this type
because increaseed risk of metastasis
• Rapidly growing nodules that my bleed or ulcerate
• Can be heavily pigmented or amelanotic and erythamatous, thus, can be
confused with benighn vascular lesions
• Can develped denovo or pre-exisitng nevis or from SSM

17. Nodular melanoma

18. Lentigo maligna melanoma
• Frequency 5-15%
• Most commonly in elederly >60 years.
• This is biologically different and arises from a prolonged pre-invasive
phase, lentigo maligna
• Very slowly expanding, pigmented, macular lesion, usuallu on head
and neck sites of elderly patients
• This phase may last for several years before a nodule or invasive
melanoma develops.

19. Acral lenitiginous or palmoplantar melanoma
• It accounts for 10% of melanoma in fairskinned races but more
common in dark people, accounting for 50% of cases
• Arises on palms,soles, and nail apparatus
• UVP exposure may not be implicated in acral melanoma risk

20. Subungual melanoma
• This form is rare
• Painless, proximally expanding streak of pigmentation arising from
nail matrix, and progrss to nail dystrphy,, and involvmenet of the
adjacent nail fold (Hutchinson’s sign)

21. Subungal melanoma

22. Clinical staging: Breslow thickness
• It is thType equation here.e maximal depth from granular layer to ddepest
tumor cells

23. Diagnosis approach
• The challenge is to disinguis between benign and malignant
• Carefull history and examination are essential

24. History
• History about:
• Lesions:
• Site
• Other similar lesions
• When it was first noted
• Change in size, shape, coloration, ulceration
• Bleedings
• Personal history of melanoma
• Sun exposure
• Child history of sunburns
• Immunosupression drugs
• Constitional symptoms

25. Physical examination
• Entire surface of skin
• ABCDE rule
• Asymmetry
• Border irrigular
• Colur irrigular
• Diamater > 0.5 cm
• Elevation irregular
• Glasgo seven points checklist
• Major features:
• Changes in size, shape, and color
• Minor features:
• Diamater > 0.5 cm, inflammation, oozing or bleeding, and itch or alteted sensation

26. ABCE Rule

27. Diagnosis and investigation
• Excisional complete biopsy with histolgic examination
• Distinguish it from benign nevus, BCC
• Determine tumor thickness and disease stage
• Chest x- ray,, bone scan, MRI, CT scan of chest, abdomen or brainm
PET Scan
• To diagnose and detect metastasis

28. Management
• Surgery
• Radiotherapy
• For metastatic disease
• Reduce pain and tumor size, doesn’t prolong survival
• Chemotherapy
• DACABAZINE
• Immuno therapy
• Bacille Calmette- Guerin vaccine
• Genitics
• tumor targeted treatments for late stage, B-Raf and c-Kit inhibitors for patients
expressing gene mutations

29. Surgery
• Wide exision of melanoma with a low risk of metastasis, stage 1
disease with a 1 cm clear margin
• The margin of excisions for more advanced disease is contervtial, but
2-3 cm margin for is common preactice
• The majority of tumors can be excised without need for grafting
• But if needed to close a wide resection, plastic surgery gives excellent
cosmotic repair.
• Stage 2 and above, a sentinel lymph node may be offered
• If biopsy came positive, local lymphadenectomy is done
• Local recurrence of the disease and local node involvement should be
treated surgically

30. Prognosis
• Prognosis for metastatic is poor and chemotherapy is palliative
• Patients with stage 1 have more than 95% chance of disease- free
survival at 10 years
• However, it drops to 50% survival with 3.5 mm thickness
• It falls to less than 10% for those with advanced nodal or metastatic
disease
• It is better in females and for tumours at certain sites such as the leg

31. Primary prevention
• Avoiding excessive direct UV exposure, especially in the middle of the
day when UV light is most
• Wearing protective clothing including a long-sleeved shirt, long pants,
and broad-brimmed hat.
• Use of sunscreen with a sun protection factor of 30 or higher. This
should protect against both UVA and UVB.
• Wearing sunglasses with 99% to 100% UV absorption to protect the
eyes and periorbital skin.
• Avoiding other sources of UV light: tanning beds and sun lamps have
been positively correlated with melanoma

32. Secondary prevention
People who at increaes risk should have annual skin examination for
early detection of melanoma or other skin lesions.

33. Screening
• Personal history of melanoma
• Family history of atypical nevi and/or melanoma, especially if the
patient has atypical nevi
• Presence of 5 or more atypical nevi
• Presence of large (>20 cm) congenital nevi
• Presence of genetic DNA repair defects, such as xeroderma
pigmentosum
• Immunosuppression: for example, with organ transplantation.

34. References
• Davidson 22nd edition
• BMJ best practive