Melanoma – Prevention, Detection and Treatment

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Sun safety needs to start at an early age in order to reduce the risk for skin cancer. In this lecture, you will learn about prevention, diagnosis, sun safety tips and new treatments for skin cancer to help you and your family reduce your risk.

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  • Welcome to Summit Medical Group’s Community Lecture on Melanoma Prevention Detection and Treatment. My name is Dr. Stephanie Badalamenti I look forward to tonights conversation speaking with you all about the topic of melanoma I’m sure many of use have been touch by melanoma either personally through family members or friends others may just have read or hear about melanoma in news and all of the interesting updates and exciting developments in the treatment of melanoma. I hope tonights lecture we can go over the basics of melanoma and touch on some of the newest thinking regarding melanoma
  • This slide is a map of of our destination this evening we’ll talk about what is a melanoma we’ll define the magnitude of the problem we’ll talk about what we can do to prevent melanoma some of the best ways to detect melanoma we will also reviewe how we diagnosed melanoma and our treatment options for melanoma.
  • This is anillistration of the skin there are three layers the epidermis, dermis and subcutanous fat. There is hair and sweat glands and blood vessels. Lets look at the inset here you see the cells of the top layer, squamous cells, basal cells and the blue cell is a melanocyte. This melanomcyte cell is responsible for the color of our skin and when this cell grows out of control it is called melanoma. Melanoms is a collection of these melanocytes.
  • Here we see the skin again on the left are the we see the three layers and on the right we see a brown lump this brown lump is a collection of melanocytes and as we progress across the slide to the right the brown lump grows deeper. How far this brown collection of melanocytes progression down into the skin is the single most important factor in survival of melanoma. The deeper the melanoma the higher the stage. Lets again look at the middle of the slide when the brown spot is just on top of the skin this is stage 0, as it goes deeper we have stage 1, and 2. Deeper invasion with a few cell escaping into the lymphnode is Stage 3, and finally when the collection has gone deep enough that it slides into the other organs it is known as stage 4.
  • This slide demonstrates the importance of catching melanoma early. As you can see whenmelanoma is limited just to the skin which we find an 84% of all cases of melanoma our survival rate is excellent. However once the melanoma slips into the lymph node our survival drops off . If the melanoma slips into other organs our survival drops off even further. I would like to touch on this 15.1% 5 years survival this number will change over the next few years. The reason this number improve is because of the new explosion of targeted treatments for melanoma which are showing dramatic results. However despite the optimisim I have towards the future of stage IV melanoma it’s certainly clear our goal should be in prevention and early detection catching melanoma early is our goal
  • This slide shows the same point but visually the yellow line is very thin melanoma the blue line is melanoma deceminated into other organs and you can see the difference in survival. This is why we are here tonight it is very slide that brings us to gather so we can work towards prevention and early detection of melanoma for ourselves her family members are friends in our community
  • Now lets move on to the magnitude of the problem.
  • On the Y axis we see lifetime risk and on the x the calandar year. In 1930 we had a one and 1500 chance of getting melanoma today in 2014 we have approximately a one and 52 chance. Current is going the wrong way we want to decrease cases while all the reasons the curve goes up is unclear some of this appears to be our increase exposure to sun
  • So we are dealing with a cancer that we can see on the skin that is easy to screen for and yet the curve is going in the wrong direction. So lets talk about ways to change the curve
  • Let’s look at preventing melanoma
  • The development of melanoma is complex and there are several risk factor which increase your likely hood of getting melanoma. The amount of time you spend in the sun both cummulative and intermitant burns is strongly corrolated with development of melanoma, your family history, your number of unusual moles or dysplstic nevi, the overall number of moles, younger women and older men, your skin type the lighter completected the higher the risk red head light skin are at particularly high risk to a lesser extent occupation. Bankers workers are at more risk because it is therorized that the get severe intermitant burns, finally the wealthier you are the higher your risk presumable because during your leisure time you get sun burns say by flying to Costa Rica. However as complex as these factors are when we look at this slide which risk can be modified? …… Ultra Violet Radiation…..
  • Ultraviolet radiation comes from either tanning salons or natural sun light
  • Lets start with modifying our risk to tanning salons. Do not go to tanning salons and you will have modified one risk factor.
  • Tanning is not a trivial source of ultraviolet light exposure. I think you find at shocking doubt 40-50% of our light-skinned 16-17-year-old girls have gone tanning. I think he’ll be amazed at 2.3 million adolescence goal per year and 30 million alcohol per year in they’re more tanning salons for city and Starbucks or McDonald’s this ultraviolet light exposure received in tanning salons increases her risk of melanoma by 75% and fortunately legislation was passed in New Jersey on April 1 Bening tanning salons and children 17 and under and requiring mental consent and 17-18-year-old. Our take away from this slide is that this is not an insignificant problems. That many people have had this exposure. We need to educate those who’ve had this exposure about their lifelong increased risk of melanoma and make sure they get yearly skin cancer screenings. YOU CAN GET A SPRAY TAN
  • Natural sunlight is correlated with the development of melanoma , 5 sunburns doubles your risk of melanoma. While cumulative sunlight increases your risk it appears that the intermittent sun exposures or the intermittent sunburns are even more correlated with melanoma People living at higher altitudes or those who have leasure time in sand and snow have increase exposure.
  • Minimizing your sun light exposure or ultraviolet radiation can be done with 3 simple steps: avoid direct sunlight between 10-4 or slip into the shade, wear sun protective clothing or slap on a hat an sun protective clothing or apply sunscreen slop on sunscreen. In fact these 3 principals known as slip,slap, slop have been incorporated into a public health program used in Australia the melanoma capital of the world
  • Prednisone between 10 and 4 enjoy activities in the shade seek out trees
  • Or we can seek shade structures while out door. This is a photograph of a shade structure at a local town pool. Seeking shade allows us to enjoy the outdoors encourage our door activities and avoid the harm of mid day sun.
  • Another way to enjoy our time out doors is to do so in sun protective clothing as seen here. This is an advertisement for one company and they state “ Take on the water. Smart swimwear that blocks 98% of UV wet or dry”.. Sun protective clothing can now be found for all occasions and in many styles. We now have stylish options for sun protectioin
  • Finally if you do not seek shade and you do not have sun protective clothing use sunscreen to decreases your exposure to the damaging effects of sun light or ultraviolet radiation.
  • The topic of sunscreen is complicated there are many types of sunscreens and there are many brands of sunscreens but there are a few points that need to be clarified. You need to apply 1-2 ounces of sunscreen application it should be applied 30 minutes before you go out because it takes some time for the sunscreen to set on the skin. Sunscreen needs to be reapply every 2 hours. And when your outdoors SPF 30-50 is sufficient there is no real benefit from SPF greater than 50. This slide simplifies a complex topic but here is a bottle of sunscreen this is an 8 ounce bottle which means for the 4 family members this is one application to last 2 hours. Generally the studies show we don’t apply enough nor do we reapply.
  • Sun protection is threefold it’s staying out of the sun , wearing sun protective clothing, and wearing sunscreen
  • So you might be asking yourself .Does this really work? Well 20 years ago Australia implement this public-health campaign and they have achieved a real results. More people are using sun protection, fewer people getting sunburns and this has translated into decreased thickness of melanoma at presentation. This is our goal get every one on the yellow line !
  • Again the yellow line . Early detection saves lives
  • Okay to improve detection well we can increase those on the look out for melanoma. That’s what we’re hoping to do today through this lecture by an transforming you into the melanoma detectors. Just having you know that some spots are dangerous is a start, but hopefully you will learn a few easy clues to detect melanoma and finally you already know but I will review whom you “my army of detectors “ who needs to get screened. But the work is not all on you bring them in… it is on me and my dermatology collegues to do our best using not only the ABCEDE’s of melanoma but to add simple tools that increase our rate of detection of melanomas.
  • Lets take a few minutes to learn to “Spot a Spot” as we learn the ABCDE’s of melanoma
  • Now I want to discuss screening for melanoma. This is the gray area of medicine there are no guidelines for melanoma screenings for the general public the only guidelines exist for those people who’ve already had melanoma. So there is debate as to who we should screen without having any guidelines. You should recommend friends and family with the new or changing moles, those with a history of melanoma. Those who have a family history of melanoma meaning really first-degree relative of melanoma. Anyone with a significant tanning usehistory should be screened an older man have the highest mortality from melanoma and they should be screened. Currently there are no recommendations for yearly screening for all of the public this may be due to insufficient data supporting the screening of the public. Every patient who comes to me as a new patient for whatever reason be it keloids, acne, warts, shingles, wrinkles EVERY SINGLE PATIENT GETS SCREENED. My staff educates every patient about the ABCDE’s of melanoma and we touch on high risk individuals. This not a guideline this is my formula.
  • I want you to send your self, her family or friends to get skin exams from board-certified dermatologists. Why? Because there is evidence that shows that we are the past at detecting melanoma subcutaneous didn’t see a doctor for a concerning lesion make sure there are board-certified dermatologist. Every dermatologist at Summit medical group is board-certified. There are people who practice dermatology who are not trained in dermatology they have done their training in another field of medicine. You can check with Dr. is education on the Internet and make sure they are trained in dermatology
  • Once she found a board-certified dermatologist minibus use a hand-held device call the dermatoscope. Studies show this to tool improves our accuracy at identifying melanomas. This tool gives us another pattern to corralate with the ABCDs of melanoma.
  • This is a dermatoscopic image of melanoma. It provides different detail not seen with the naked eye and adds information to decide to biopsy or not. This technology improves a healthcare provides ability to detect melanoma and non melanoma skin cancers.. This technology is behind the new product “melafind” as well as the “molesafe” clinics. I use this technology every day.
  • Here we have 25 poses which represents the standard full body photography. This captures every mole on your body. These are generally used in patinets with a history of melanoma in themselves. This very clearly helps identify any ABCDE changes. Together you through spoting a spot and the abcde’s and knowing who is most at risk and me with my board certification, my insterst in melanoma, my use of technology we will improve detection.
  • The decision to biopsy can be made with a phycisian or patient eye for ABCDE’s of melanoma, the ugly ducklying rule and/or dermascopic changes but you are not diagnosed with melanoma until the tissue is removed and read under a microscope. The dermatologist removes the tissue and send it to another physician to look at it under the microscop
  • This is another important piece of information. Your dermatologist should use a board certified dermatopathologist to read the sample. They are particularly trained at diagnosis melanoma. All the dermatologist at Summit Medical Group use board certified dermatopathologist with expert training in melanoma diagnosis. After all it is the dermatopathologist who makes the diagnosis. The patient and the dermatologist decide to biopsy but you don’t know until the dermatopathology report comes back
  • When the dermatopathologist looks at the tissue they right a whole bunch of stuff on the report let’s just focus on the left side. Let’s look at the top line to her sick thickness this is the brown blob in half arch grown down into the skin on her important things include letters ulcerated or what the mitotic rate is but I don’t want to get deep into this report suffice to say he should have a board-certified dermatopathologist and they are the ones to make a diagnosis and that the most important piece of information when you. The diagnosis of melanoma is what is the depth
  • And the depth gets back to this initial slide on staging how far the brown lump grew down into the skin. In stage 0-2 it stays on the skin , in stage III it slipped into the lymph node and stage IV it’s in other organs. How do we know if it slipped into the lymph node? At a certain depth we start to wonder and that depth leads us to check the lymph node. Generally that deepth is beyond 1 mm
  • So here we have a patient who’s dermatopathology report showed a melanoma to be greater than 1 mm. Here is the melanoma and we inject blue dye and the dye drains to lymph nodes and we find them and check the blue ones. This analysis of the lymph node gives us staging information and then treatment guidelines
  • Again the slide shows S. that most of a melanoma is 84% of them are found just on the skin and he is thighs get a simple excision of the melanoma no other testing is required no blood work no chest x-rays just excision
  • Bottari excise a melanoma we decide how much extra tissue or margins we need to take and that has to do with how far the brown lump grew into the skin
  • This is a melanoma and were taking 1 cm margins the dermatologist or the surgical oncologist are both trained to excise this small lesion. We provide the patient with a simple injection of lidocaine and excise the tissue. Generally I prefer a second set of eyes so I send this to our surgical oncologists.
  • This is this is the result a simple scar with stiches and the patinet is awake alert and walks out.
  • Mr. Mc Cain has had 5 melanomas. He represents the case that a high risk group white older men, with a history of UV exposure and with a history of melanoma. On his left temple he had a stage IIa melanoma and had his sentinal node removed it was negative. That was the end of his treatment and now he gets regularly survalince
  • From 1970- 2011 there were 2 or 3 medications with limited efficacy used in the treatment of melanoma. In 2011 there were 2 more so we double our treatment in 1 year. In fact the data was so impressive that the clinical trial was stopped early when there was clear survival benefit seen with Zelboraf. The is an increadible pace at which new more targeted biologic drugs have been developed.
  • Okay don’t fall into a glazed look. This slide shows the hope of the future in treatment for melanoma. This may be the most amazing information I share with you. I will take you through it there are 3 cells to the right an immune cell, to the left an immune helper cell and at the bottom a melanoma cell. In these cells each red lines show future molecules which we are targeting now to stop melanoma. So lets just count them 11 NEWLY identified target. This is amazing!! So one may work in some melanomas other may work in others we may need a few at once but at least now we have a cabinet full of possiblities.
  • This slide represents dermatologists who does not know how to make figures with a computer. So this is my hand-drawn explanation for decreasing mortality rates from melanoma it really is prevention ,detection of the treatment together
  • I would like to thank my fellow dermatologist at SMG I believe this is the most well trained dermatology group anywhere. It is a pleasure to work with them and they are all dedicated to their craft.
  • This is a apperatus that takes panoramic photos and stores them and evey time you go to the physician with this it reimages you and using software identifies candidate “changing” moles. This technology is located at one location in USA
  • Melanoma – Prevention, Detection and Treatment

    1. 1. Melanoma Prevention, Detection, Treatment Stephanie Badalamenti MD-PhD Dermatologist SMG West Orange , NJ May 1, 2013
    2. 2. Melanoma • Define Melanoma • Magnitude of Problem • Prevention • Detection • Diagnosis/Staging • Treatment
    3. 3. What is Melanoma
    4. 4. What is Melanoma
    5. 5. Melanoma Survival Stage at Diagnosis Stage Distribution 5 yr survial Localized (primary site) 84% 98.2% Regional spread(nodes) 9% 62.4% Distant spread organs 4% 15.1%
    6. 6. What is Melanoma
    7. 7. Melanoma • Define Melanoma • Magnitude of Problem • Prevention • Detection • Diagnosis • Treatment
    8. 8. Magnitude of Problem
    9. 9. Melanoma • 120,000 detected each year • 8,700 death per year
    10. 10. Magnitude of Problem • Most early detectable cancers: colorectal, breast, cervical and prostate have demonstrated substantial declines over the past 3 decades melanoma mortality rates have continued to rise
    11. 11. Melanoma • Define Melanoma • Magnitude of Problem • Prevention • Detection • Diagnosis/Staging • Treatment
    12. 12. Melanoma Risk Factors • Sun Exposure (Ultra Violet Radiation) • Family history of Melanoma • Dypslastic nevi • More than 50 moles • Age/Gender • Skin type • Occupation • Socioeconomic Status
    13. 13. Energy
    14. 14. Sunshine Rays
    15. 15. Ultraviolet light
    16. 16. Modifiable Risk Factors Sunshine/ Ultraviolet Radiation • Tanning Salons • Sunshine
    17. 17. Tanning Salon
    18. 18. Tanning Salons • 40-50% of 16-17 year old girls • 2.3 Millions adolescents yearly • More tanning salons per city then Starbuck or McDonalds • Increase risk of Melanoma 75% • Legislation was passed NJ April 1, 2013  Banning tanning under age 17
    19. 19. Natural Sunlight
    20. 20. Natural Sunlight • 5 sunburns doubles your risk of melanoma • Cumulative and intermittent sun exposure • High Altitudes increase exposure • Reflection off sand and snow increase exposure
    21. 21. Minimize Sunlight • Avoid Sun 10-4 pm Slip • Sun Protective Clothing Slap • Sunscreen Slop
    22. 22. Seek Shade
    23. 23. Seek Shade
    24. 24. Sun Protective Clothing
    25. 25. Sunscreen
    26. 26. Sunscreen
    27. 27. Sunscreen • 1-2 ounce • 30 minutes prior exposure • Reapplied every 2 hours • SPF 30- 50
    28. 28. sunscreens • Creams • Sprays
    29. 29. Sun protection • Slip • Slap • Slop
    30. 30. Does modifying sun exposure work?  Increases use of sun protection  Decrease sunburns  Decrease thickness of melanoma
    31. 31. Melanoma • Define Melanoma • Magnitude of Problem • Prevention • Detection • Diagnosis/Staging • Treatment
    32. 32. Detection • Increase the detectors  General Public • Spot the Spot • ABCDE’s • High Risk Patient • Improve the detectors  Technology • Dermoscopy • Full Body Photography
    33. 33. Melanoma ABCDE’s
    34. 34. Asymmetry
    35. 35. Benign Mole — Symmetrical
    36. 36. Melanoma Asymmetrical
    37. 37. Melanoma — Asymmetrical
    38. 38. Border
    39. 39. Benign Mole — Even Edges
    40. 40. Melanoma — Uneven Edges
    41. 41. Melanoma — Uneven Edges
    42. 42. Color
    43. 43. Benign Mole — One Shade
    44. 44. Melanoma — Two or More Shades
    45. 45. Melanoma — Two or More Shades
    46. 46. Diameter
    47. 47. Benign Mole — 6mm or Smaller
    48. 48. Melanoma — Larger than 6mm
    49. 49. Melanoma — Larger than 6mm
    50. 50. Evolving
    51. 51. Melanoma — a Mole that Changes
    52. 52. Screening High Risk Patients • New or Changing Mole ABCDE’s • History of Melanoma • Family history Melanoma • Tanning salon users • Older men • All new patients
    53. 53. Screening • American Caner Society  Every 3 years between 20-40 years  Every year over 40 year
    54. 54. Improving the Detectors • Dermatologist are the best at finding melanoma
    55. 55. Dermoscopy
    56. 56. Dermoscopy
    57. 57. Full Body Photograph
    58. 58. Melanoma • Define Melanoma • Magnitude of Problem • Prevention • Detection • Diagnosis/Staging • Treatment
    59. 59. Biopsy
    60. 60. Excisonal Biopsy
    61. 61. Skin sample
    62. 62. Skin tissue processed
    63. 63. Dermatopathologist
    64. 64. Dermatopathologist Essential • Tumor thickness • Ulceration • Mitotic rate • Margins • Anatomic Level • Microsatellitosiss Optional • Angiolymphatic Invasion • Histologic Subtype • Neurotropism • Regression • T stage • Tumor infiltrating lymphoctes and vertical growth phase
    65. 65. Staging
    66. 66. Sentinal node biopsy
    67. 67. Melanoma • Define Melanoma • Magnitude of Problem • Prevention • Detection • Diagnosis/Staging • Treatment
    68. 68. Melanoma Survival Stage at Diagnosis Stage Distribution 5 yr survial Localized (primary site) 84% 98.2% Regionalspread(nodes) 9% 62.4% Distant spead 4% 15.1% Unkown 4% 75.8%
    69. 69. Surgical Treatment
    70. 70. Summit Medical Group • Prevention • Detection  Well informed patients  Well trained dermatologist • Diagnosis  Dermatopathologist • Treatment  Integrated team dermatologists, surgeons, oncologists
    71. 71. Surgical Treatment
    72. 72. Surgical Treatment
    73. 73. Surgical Treatment
    74. 74. Surgical treatment • If melanoma is found in the sentinal lymph node the lymph nodes in that section may be removed
    75. 75. Medical Treatment • Radiation Therapy • Chemotherapy • Biologic therapy  Ipilimumab/ Yervoy  Vemurafenib/ Zelboraf • 5% vs 48%
    76. 76. 11 Possible Medications
    77. 77. Melanoma • Define Melanoma • Magnitude of Problem • Prevention • Detection • Diagnosis/Staging • Treatment
    78. 78. SMG Dermatology • Monib Zirvi MD-PhD • Hari Nadiminti MD • Sam Kim MD • Gabe Gruber MD • Emily Altman MD • Naheed Abbasi MD MPH
    79. 79. Melanoscan
    80. 80. Dermoscopy Advances
    81. 81. Confocal Microscopy
    82. 82. Confocal Microscopy

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