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Melanoma
This document provides information on malignant melanoma. Some key points: - Melanoma is a malignancy of melanocytes that can occur in skin, eyes, and mucous membranes. It has a high ability to metastasize to other organs. - Incidence is increasing worldwide. Risk factors include fair skin, moles, UV exposure, and family history. - Diagnosis involves examining lesions for characteristics like asymmetry, irregular borders, varied color, and size over 6mm. Biopsies are used to confirm. - Staging uses the TNM system and considers tumor thickness, ulceration, and lymph node/distant organ involvement. Prognosis depends on stage - thicker tumors over 2mm
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Melanoma
- 1. Melanoma By Dr. Ihab Samy lecturerof Surgical Oncology National Cancer Institute Cairo University 2014 Ihab Samy 2014
- 2. MALIGNANT MELANOMA • Malignantmelanoma is a malignancy of melanocytes that occurs in the skin, eyes, ears, gastrointestinal tract, leptomeninges, and oral and genital mucous membranes. • One of the most dangerous tumors, melanoma has the ability to metastasize to any organ, including the brain and heart. Ihab Samy 2014
- 3. EPIDEMIOLOGY • The incidenceof malignant melanoma is increasing rapidly worldwide. • The median age at diagnosis is 57 years, and the median age at death is 67 years. • Whites have a 10-fold greater risk of developing cutaneous melanoma than blacks, Asians, or Hispanics. • Whites and blacks have a similar risk of developing plantar melanoma. Noncutaneous melanomas (e.g., mucosal) are more common in non-white populations. Ihab Samy 2014
- 4. CLINICAL RISK FACTORS •Fair-skinned persons. • Common and Atypical Nevi. • Giant Congenital Nevi. • Personal History of Melanoma. • Strong family history of melanoma with 2 or more first-degree relatives affected. • Ultraviolet (UV) radiation exposure, to both UVA and UVB. • Increasing age Ihab Samy 2014
- 5. A B C D E Asymmetry Border irregularity Colour variation Diameterover 6 mm Evolving (enlarging, changing) The ABCDs of Melanoma Ihab Samy 2014
- 6. Biopsy Technique • Afull-thickness biopsy is done to interpret the maximum tumor thickness and the presence or absence of ulceration accurately. • Excisional biopsy with a narrow margin of normal-appearing skin is preferred for small lesions and can be performed on most small lesions. • A thin shave biopsy of suspicious lesions should be avoided, because it may compromise histologic interpretation and proper measurement of thickness. Ihab Samy 2014
- 7. Immunohistochemistry for melanoma •The S100 protein is a calcium-binding protein. • HMB45 is an antibody against the gp-100 protein, a glycoprotein considered to be part of the premelanosome complex. • Anti–MART-1 and anti–Melan-A. • Other markers used to identify tumors of melanocytic origin include microphthalmia-associated transcription factor, melanoma-associated antigen, and tyrosinase. Ihab Samy 2014
- 8. Clark's Levels • LevelI: Intraepidermal (melanoma in situ). • Level II: Partial involvement of the papillary dermis by single cells or small nests. • Level III: Expansile nodule filling the papillary dermis and widening it, impinging upon the reticular dermis. A few cells may infiltrate the superficial reticular dermis. • Level IV: Extension of multiple cells across a broad front into the reticular dermis. • Level V: Extension into the subcutaneous fat. Ihab Samy 2014
- 9. Breslow Thickness • T1:1.0 mm or less • T2: 1.1 to 2.0 mm • T3: 2.1 to 4.0 mm • T4: more than 4.0 mm Ihab Samy 2014
- 10. T classification (thickness) •TX - Primary tumor cannot be assessed (shave biopsy, regressed primary) • Tis - Melanoma in situ • T1 - ≤1.0 mm (a: without ulceration, b: with ulceration) • T2 - 1.01-2.0 mm (a: without ulceration, b: with ulceration) • T3 - 2.01-4.0 mm (a: without ulceration, b: with ulceration) • T4 - > 4.0 mm (a: without ulceration, b: with ulceration) Ihab Samy 2014
- 11. N classification • N1- 1 lymph node; a: micrometastasis (clinically occult), b: macrometastasis (clinically apparent) • N2 - 2-3 lymph nodes; a: micrometastasis, b: macrometastasis, c: in transit met(s), satellite(s), without metastatic lymph nodes (N2a: 2-3 nodes positive for micrometastasis; N2b: 2-3 nodes positive for macrometastasis; N2c: In transit met(s) or satellite(s) without metastatic nodes) • N3 - 4 or more metastatic nodes or matted nodes or in- transit metastases or satellite(s) with metastatic node(s) Ihab Samy 2014
- 12. M classification • M1a- Distant skin, subcutaneous, or nodal metastases, normal lactate dehydrogenase (LDH) level • M1b - Lung metastases, normal LDH level • M1c - All other visceral metastases or any distant metastases with an elevated LDH level Ihab Samy 2014
- 13. Pathologic Stage TumorNode Metastasis 0 Tis N0 M0 IA T1a N0 M0 IB T1b N0 M0 T2a N0 M0 IIA T2b N0 M0 T3a N0 M0 IIB T3b N0 M0 T4a N0 M0 IIC T4b N0 M0 IIIA T1–4a N1a M0 T1–4a N2a M0 IIIB T1–4b N1a M0 T1–4b N2a M0 T1–4a N1b M0 T1–4a N2b M0 T1–4a/b N2c M0 IIIC T1–4b N1b M0 T1–4b N2b M0 Any T N3 M0 IV Any T Any N M1 Ihab Samy 2014
- 14. Types of Melanoma •Superficial spreading melanoma (about 70% of diagnosed cases). • Nodular melanoma (about 15% of diagnosed cases). • Lentigo maligna melanoma (about 10% of diagnosed cases). • Acral lentiginous melanoma (about 5% of diagnosed cases). Ihab Samy 2014
- 15. Non-pigmented Subtypes • Whileuncommon, melanoma occasionally does not have brown or black pigmentation. An uncommon subtype called amelanotic melanoma usually appears as a pink or red nodule (lump). 5% of all NMs are amelanotic melanomas. • Another uncommon subtype, desmoplastic neutrotrophic melanoma (DNM), usually looks like a non-pigmented scar. When a scar or keloid appears on the skin and the skin has not been injured, DNM is suspected. The lesion also can appear as a cyst that may or may not be pigmented. DNM tends to appear on sun-damaged skin in elderly patients, occurring mostly on the head and neck. Ihab Samy 2014
- 16. Amelanotic melanoma • Amelanoticmelanoma appears as a lesion that has little or no color (non-pigmented) or may appear red, pink or scarlike-white. • It has an asymmetrical shape, and an irregular faintly pigmented border. • Any of the types of melanoma may be amelanotic, but a particular amelanotic variety is called desmoplastic melanoma (DM). DM is most commonly found in acral lentiginous melanomas located subungually. • Their atypical appearance leads to delay in diagnosis, so worse prognosis . Ihab Samy 2014
- 17. Treatment • The mainstayof treatment of melanoma is surgical, with 2 specific goals: 1. Excision of the primary lesion with appropriate margins. 2. Evaluation of the nodal basin for staging and disease clearance. Ihab Samy 2014
- 18. • In SituMelanoma (Stage 0) :should be excised using a 0.5-cm margin from all edges of either the lesion or the prior surgical site. With in situ disease (Stage 0), excision is the sole treatment. • Lesions <1.0 mm Breslow Tumor Thickness or a Clark level II or III: wide local excision with a 1.0-cm margin is the sole treatment. • Lesions <1.0 mm Breslow Tumor Thickness with Adverse Features or Clark level thickness IV or V, have a low, but real risk for occult nodal metastasis (ie, Stage IB and Stage IIA lesions). These tumors should be resected with wide local excision of 1.0 cm from all margins and sentinel lymph node (SLN) evaluation should be considered. • Lesions Between 1.01 mm and 2.0 mm Breslow Tumor Thickness: wide local excision with margins of 1.0 to 2.0 cm from all tumor edges based on the ability to achieve primary closure. Patients with these lesions without clinical evidence of regional nodal disease should undergo sentinel lymph node evaluation. • Lesions >2.01 mm Breslow Tumor Thickness: wide local excision with 2.0 cm radial margins from all tumor or prior surgical excision margins. Patients with these lesions without clinical evidence of regional nodal disease or metastatic disease from staging studies should undergo sentinel lymph node evaluation. Ihab Samy 2014
- 19. Management of LymphNodes • The use of sentinel lymph node biopsy in melanoma is accepted as an appropriate method of accurately staging individuals who may have occult nodal metastasis. • With the current AJCC staging model, all individuals with a Stage Ib or higher melanoma without clinically positive lymph nodes should be offered a sentinel lymph node biopsy. Ihab Samy 2014
- 20. • Clinically palpablelymph nodes should be considered to have regional disease. A complete regional lymphadenectomy is indicated. • A complete lymph node dissection should include an anatomically complete dissection of the entire nodal basin involved. • In the axilla this is usually a Level I and II axillary dissection. Ihab Samy 2014
- 21. Adjuvant therapy • Currentlyinterferon-ɑ2B is the only adjuvant therapy regimen for malignant melanoma approved by the Food and Drug Administration. • Numerous evaluations with different dose regimens and timing have all concluded that although there is an extension of relapse-free state, overall survival to 12.6 years is equivalent. • The use of such a regimen should be made on an individual patient basis. Ihab Samy 2014
- 22. Stage IV andmetastatic melanoma • If at the time of presentation it is established that the patient can undergo primary resection of the initial lesion in conjunction with the solitary distant disease, this should be attempted. • Following surgery the patient should be offered adjuvant therapy with interferon-ɑ2B or a clinical trial. • Those patients who are not candidates for resection due to either widespread metastatic disease or incomplete resection should be treated with an advanced chemotherapy regimen or referred for clinical trials. Ihab Samy 2014
- 23. Isolated limb perfusion •The arterial supply and venous drainage are surgically isolated through an open incision, and an oxygenated extracorporeal circuit is used to circulate chemotherapeutic agents for 1 to 1.5 hours. • Melphalan is typically used as a chemotherapeutic agent, and the limb temperature is typically elevated to 39 to 40°C with a tourniquet in place. Ihab Samy 2014
- 24. Isolated Limb Infusion •Isolated limb perfusion can be effective for in- transit metastases, however it is time- and resource-consuming and can be toxic. • One alternative to this approach involves normothermic isolated limb infusion (ILI). • Melphalan is typically used as a chemotherapeutic agent. Ihab Samy 2014
- 25. Isolated limb perfusionIsolated limb infusion Technically complex Open surgical exposure of vessels for catheter insertion 4 to 6 hours duration Complex and expensive equipment Higher perfusion pressures predispose to systemic leakage Limb tissues oxygenated, with normal blood gases maintained Hyperthermia (>41°C can be achieved) General anesthesia required Technically simple Percutaneous vascular catheter insertion in radiology department Approximately 1 hour Equipment requirements modest Low pressure system, effective vascular isolation with tourniquet Progressive hypoxia and acidosis Usually not possible to raise limb temperature above 40°C Possible with regional anesthesia Ihab Samy 2014
- 26. Case Presentation • 65years od female patient presenting with large left iliac mass extending to left lumbar and hypochondrial regions. • History 2 months ago of excision of a small exuberant heel ulcer about 1.5 X 1 cm. • Pathology revealed: Amelanotic melanoma, T4b, Clark’s level V; focally infiltrated surgical margins. Ihab Samy 2014
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- 29. • CT Abdomenand pelvis (13-11-2011): Large oblong retroperitoneal cystic collection at left iliac region extending to left lumbar region measuring 22 X 5 X4 cm. Extending sup. To reach lower pole of spleen, displacing lt. kidney medially + multiple enlarged inguino- iliac LNs 1-3.5 cm. in diameter. Ihab Samy 2014
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- 32. • Follow- upCT Abdomen and pelvis (07-12- 2011): Progressive course since the last study regarding the left ilio-lumbar cystic mass and stationary course of lymphadenopathy. Ihab Samy 2014
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- 35. • CT guidedaspiration cytology of 5 cc. of turbid hemorrhagic fluid on (13-12-2011): Exudative reaction. (No Atypia or Malignancy) Ihab Samy 2014
- 36. • Exploration doneon 15-01-2012 through a generous midline incision revealed a large cystic mass covered by omentum occupying the lt. iliac, lumbar and hypochondrial fossae. • The mass was dissected from lt. ureter and iliac vessels inferiorly up to lt. kidney, stomach and spleen superiorly Ihab Samy 2014
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- 41. Left ureter afterits complete dissection and release from the mass. Ihab Samy 2014
- 42. • Complete inguino-iliaclymphadenectomy was done after excision of the mass in toto with the overlying omentum. Ihab Samy 2014
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- 44. Complete iliac nodaldissection Ihab Samy 2014
- 45. The residual heelulcer was completely excised with safety margin and left raw to heal by granulation tissue Ihab Samy 2014
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- 47. • No postoperativecomplications and the patient was discharged on 24-01-2012. • Follow-up showed no late complications and good healing of the area excised at the heel. Ihab Samy 2014
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- 49. Pathology report • Largemetastatic mass 20 X 20 X 13 cm. of malignant melanoma, congested omental tissue. • Totally collected 15 lymph nodes with 7 showed metastatic deposits. • Skin of heel excised showed NO remnant of tumor tissue. Ihab Samy 2014
- 50. The patient nowis receiving Interferon and chemotherapy and she is free till now from local recurrence and distant metastases. Ihab Samy 2014
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