Malignant melanoma is a skin cancer from uncontrolled growth of melanocytes, primarily caused by genetic factors and UV exposure, with increasing worldwide incidence. Diagnosis involves clinical evaluation, pathology, and imaging to determine staging, with treatment options including surgery, chemotherapy, and radiotherapy. Early detection is crucial for a favorable prognosis, with survival rates varying significantly based on tumor thickness and other factors.

1. Malignant MelanomaMalignant Melanoma
Dr Foroogh MousaviDr Foroogh Mousavi

2. What is melanomaWhat is melanoma
 Skin malignancy that is the result of uncontrolledSkin malignancy that is the result of uncontrolled
multiplication of melanocytes.multiplication of melanocytes.
 Melanocytes are a group of cells in the superficialMelanocytes are a group of cells in the superficial
layer of the skin that produce melanin ( a darklayer of the skin that produce melanin ( a dark
pigment) as a response to ultraviolet light.pigment) as a response to ultraviolet light.
 Other forms: ocular , visceralOther forms: ocular , visceral

4. EtiologyEtiology
 Genetics : p16,p19,ras.Genetics : p16,p19,ras.
 UV exposure , by various mechanisms includingUV exposure , by various mechanisms including
damaging melanocytes DNA.damaging melanocytes DNA.
 Sunburn : intermittent, blistering sunburns.Sunburn : intermittent, blistering sunburns.
 Warning signs: changing moles, positive familyWarning signs: changing moles, positive family
history, previous history of melanomahistory, previous history of melanoma

5. EpidemiologyEpidemiology
 Highest incidence rate in Queensland ,Australia:Highest incidence rate in Queensland ,Australia:
57 per100,000.57 per100,000.
 Rapid increase in incidence worldwide, only secondRapid increase in incidence worldwide, only second
to lung cancer. Risk: 1 in 1500 in 1935 , 1 in 75 into lung cancer. Risk: 1 in 1500 in 1935 , 1 in 75 in
2000.2000.
 Gender demographics :M>FGender demographics :M>F
 Average age of diagnosis : 57 yrs, rare in <10 yrs.Average age of diagnosis : 57 yrs, rare in <10 yrs.

6. DiagnosisDiagnosis
 Clinical: checking suspicious lesion , ABCD.Clinical: checking suspicious lesion , ABCD.
 Pathology/biopsy : confirms diagnosisPathology/biopsy : confirms diagnosis
 Imaging: staging and spreadImaging: staging and spread

8. StagingStaging
 According to skin layers involved ( Clarke):According to skin layers involved ( Clarke):
 Level I : epidermis, Level II to IV : dermis, Level V:Level I : epidermis, Level II to IV : dermis, Level V:
subcutaneous fatsubcutaneous fat
 According to depth (Breslow): 0.75 mm, 0.76-1.5,According to depth (Breslow): 0.75 mm, 0.76-1.5,
1.51-4mm, > 4mm.1.51-4mm, > 4mm.
 TNM :Thickness and ulceration, Nodes , MetastasisTNM :Thickness and ulceration, Nodes , Metastasis

9. Nodal assessmentNodal assessment
 Sentinel node biopsy :Sentinel node biopsy :
 Indicated if >1mm thickIndicated if >1mm thick
 Sentinel node : the very first draining lymph nodeSentinel node : the very first draining lymph node
 Blue dye or Tc radioisotopeBlue dye or Tc radioisotope

11. Melanoma on medicalMelanoma on medical
imagingimaging
 Chest radiograph :Chest radiograph :
-Routinely obtained on diagnosis-Routinely obtained on diagnosis
-Usually negative on stage I and II: usually negative ,-Usually negative on stage I and II: usually negative ,
provides a baseline for future comparison.provides a baseline for future comparison.
- Important to obtain in stage III and higher : first- Important to obtain in stage III and higher : first
metastatic site are lungs.metastatic site are lungs.

13. Melanoma on medicalMelanoma on medical
imagingimaging
 CTCT
 Head : brain mets assessmentHead : brain mets assessment
 Chest: indicated in stage IV disease to detectChest: indicated in stage IV disease to detect
asymptomatic metsasymptomatic mets
 Abdomen : stage III, in-transit and locally recurrentAbdomen : stage III, in-transit and locally recurrent
usually low yield but provide a base line.usually low yield but provide a base line.
 Pelvis : only when primary region is below the waistPelvis : only when primary region is below the waist

14. 58 year old female who developed left-handed weakness. A. Non-contrast melanoma
on CT, usually has a hemorrhagic appearance. B. Contrast enhanced CT , mets show
contrast enhancement due to destruction of blood-brain barrier.
AA B

15. Medical imagingMedical imaging
 MRI : brainMRI : brain
Only in case of known mets or symptomatic patients.Only in case of known mets or symptomatic patients.

16. A 55 yr female with melanoma of right leg and hemorrhagic
metastasis to the brain.
T1: large hyperintense lesion left posterior parietal lobe.
Increased conspicuity of smaller lesions on post-Gad.

17. Melanoma on medicalMelanoma on medical
imagingimaging
 PET :PET :
 Indicated for staging of known nodal disease, in-Indicated for staging of known nodal disease, in-
transit diseasetransit disease
 Therapy responseTherapy response
 Pre-operative assessment ( excluding mets)Pre-operative assessment ( excluding mets)

18. A
B
82 year old male with
right knee melanoma.
A.Initial PET scan
showing intensely
FDG right knee
lesion.
B. progressive disease
, cutaneous ,
subcutaneous and
intramuscular mets.

19. 67 year old male with
resected lip, shoulder
and scalp melanoma.
Also confirmed
duodenojejunal
junction melanoma.
Brain mets found on
staging PET

20. Course and prognosisCourse and prognosis
 Curable if detected early. Usual presentations are onCurable if detected early. Usual presentations are on
extreme ends of spectrum.extreme ends of spectrum.
 Depends on :Thickness, ulceration, nodal involvement,Depends on :Thickness, ulceration, nodal involvement,
metastasis.metastasis.
 If up to 1mm thick , no ulceration and no nodalIf up to 1mm thick , no ulceration and no nodal
involvement : 95 %, 5 year survival .involvement : 95 %, 5 year survival .
 If 4 mm and ulcerated: 45% 5yr survivalIf 4 mm and ulcerated: 45% 5yr survival
 If ulcerated lesion & positive node: 24-29%If ulcerated lesion & positive node: 24-29%
 Lung mets : 7% , 5 yr survivalLung mets : 7% , 5 yr survival

21. TreatmentTreatment
 Surgery : wide local excision, Sentile node excision,Surgery : wide local excision, Sentile node excision,
brain mets ( symptomatic )brain mets ( symptomatic )
 ChemotherapyChemotherapy
 RadiotherapyRadiotherapy

22. ReferencesReferences
 emedicine.comemedicine.com
 Radiopedia.orgRadiopedia.org
 Dermnetnz.orgDermnetnz.org