Malignant Melanoma.pptx

For surgical residents presentation

1. Malignant Melanoma By Dr. Olofin K.E Registrar surgery Dept WDH

2. Outline Introduction Epidemiology Pathology Risk factors Clinical and pathologic staging Clinical presentation Management Prognosis Conclusion References

3. Introduction Malignant melanoma is the most deadly form of skin cancer, It has the highest mortality rate of all dermatological cancers One of the most common cancer in young adults

4. Epidemiology The incidence has been steadily increasing over the past 50 years (currently 20 in 100,000 people ), I t is the fifth most common malignancy in men and the seventh in women , and 1 in 52 people will be diagnosed with melanoma in their lifetime . Although melanoma accounts for less than 5 % of all skin cancer cases, it results in greater than 75% of skin cancer deaths.

5. Median age 55 years for both sexes About the same number in both sexes In males the highest incidence and fastest increase are in trunk melanomas In females the highest incidence and fastest increase are in melanomas of the lower leg

6. Pathology Melanoma is cancer of the melanocytes . Melanocytes are located in the Stratum Basale and produce melanin .

7. When skin is exposed to sunlight, melanocytes produce more pigment, causing the skin to tan. Sometimes , clusters of melanocytes form noncancerous ( benign) growths called moles . Moles can be either flat or raised, round or oval, and are smaller than a pencil eraser. Generally harmless, but can become cancerous

8. Risk Factors Family history of melanoma (10%) Dysplastic nevi (noncancerous, but unusual- looking moles ) Previous melanoma (5%) Many nevi (ordinary moles ): more than 50 Severe , blistering sunburns Freckling tendency Fair skin Excessive use of tanning beds Genetic predisposition

9. It is important to note that while intense sun damage is very strongly associated with melanoma, I t is not necessarily required for malignant transformation , as a significant number of lesions arise in relatively sun protected areas (soles of feet, anus, and vagina)

10. Clinical presentation C an appear suddenly as a new mole or develop slowly in or near an existing mole . In men, melanomas are often found between the shoulders and hips, or the head and neck area. In women, melanoma often develops on the lower legs as well as between the shoulders and hips . It may also appear under the fingernails or toenails or on the palms or soles

11. ABCDE of melanoma A is for Asymmetry : – One half of a mole or birthmark does not match the other. B is for Border : – The edges are irregular, ragged, notched, or blurred. C is for Color : – The color is not the same all over and may include shades of brown or black, or sometimes with patches of pink, red, white , or blue. D is for Diameter : – The spot is larger than 6 millimeters across (about ¼ inch – the size of a pencil eraser), although melanomas can sometimes be smaller than this. E is for Evolving/elevated: – The mole is changing in size, shape, or color.

12. Clinical and pathologic staging Histogenetic type Superficial Spreading Melanoma (50-70%) Nodular Melanoma (trunk) Lentigo Maligna Melanoma (face) Acral Lentiginous Melanoma (palmes and soles ) Amelanotic

13. Superficial spreading melanoma presents as flat or slightly elevated lesion with variegate pigmentation most commonly occurring on the trunk in men and the legs in women, in patients aged 30 to SO years.

14. Nodular melanoma Second most common type (15%) Vertical growth pattern Worst prognosis based on a higher average tumor thickness. frequently affecting the legs or trunk.

15. Lentigo maligna melanoma Sun-damaged skin Flat,darkly pigmented lesion with irregular borders and a history of slow development

16. Acral lentiginous melanoma Seen in blacks Commonly occurs on the palms of the hand, sole of the feet, or beneath the nail plate ( subungual ) presents at a more advanced stage with an aggressive course compared with the other subtypes.

17. Amelanotic Melanoma Uncommon Difficult to diagnosis Lacks pigmentation presents as an unremarkable plaque or nodule can easily be misdiagnosed at an early stage.

18. Stage (Clark’s level or Breslow Depth)

19. Clark Classification (Level of Invasion ) Level I : Lesions involving only the epidermis ( in situ melanoma); not an invasive lesion. Level II : Invasion of the papillary dermis but does not reach the papillary-reticular dermal interface. Level III : Invasion fills and expands the papillary dermis but does not penetrate the reticular dermis

20. Level IV : Invasion into the reticular dermis but not into the subcutaneous tissue. Level V : Invasion through the reticular dermis into the subcutaneous tissue

21. Breslow level of invasion Level 1: 0.0-0.75mm Level 2: 0.76-1.50 mm Level 3: 1.51-3.0 mm Level 4: >3mm

22. Management History Examination : All patients diagnosed with cutaneous melanoma undergo a thorough skin assessment and clinical evaluation. Investigation B iopsy FBC, E/U/Cr, LFT Chest X-ray, Abdominopelvic USS, CT scanning MRI of the brain, and bone scan.

23. Treatment Excision is the mainstay of treatment Early stages : – Wide local excision More advanced : – Wide local excision plus sentinel node biopsy , Based on the pathology Lympadnectomy observation interferon Metastatic : Clinical trial Radiation and systemic therapy

24. Elective lymph node dissection (ELND) Use of prophylactic dissection (clinically negative nodes ) is controversial No prospective, randomized studies have demonstrated that elective LN dissection improves survival in patients with intermediate thickness melanomas

25. Dissection should be complete Groin dissection Deep (iliac) nodes must be removed along with the superficial (inguinal) nodes Axillary dissection All levels I, II, III should be removed Head and Neck Superficial parotidectomy to remove parotid nodes

26. Sentinel biopsy concept To define the pathway from the melanoma site to the first draining lymph node by injecting dyes and radioactive tracers If the node contains melanoma cells a proper lymphadenectomy is indicated The rate at which this occurs is between 12 % and 36%

27. Complications Wound seroma Cellulitis lymphedema

28. Radiation Used in some cases High doses Not so useful

29. Adjuvant therapy Chemotherapy Dacarbazine is drug of choice Other drugs Cisplatine Paclitaxel Docetaxel Temozolomide

30. Immunotherapy Interlukin IL-2 and Interferon on high doses Interferon has been approved by the FDA in high risk melanomas Toxic and expensive Proven efficacy only in Stage II melanomas BCG

31. Monoclonal antibodies – Ipilmumab Tumour vaccine – Polyvalent melanoma vaccine ( Canvaxin ) – Allogenic melanoma cell lysate ( Melacin ) – Detoxified endotoxin/ myco bacterial cell wall skeleton (DETOX ) – Gp 100 DNA vaccine – GM-CSF 2nd generation oncolytic herpes virus vaccine

32. Targeted therapies BRAF Inhibitor – PLX4032( vemurafenib ) KIT Inhibitor – Imantinib mesylate

33. Follow up Goals To detect a second primary melanoma (3-5%) To detect a local or regional recurrence To detect distant metastases Intervals 3 months for 5 years for lesions > 0.75 mm 6 months for 5 years for lesions < 0.75 mm After 5 years once a year

34. Prognosis Based on clinical and pathologic features Clinical features Sex: F >M Age: <60 better Site of tumor: Scalp,face,feet , trunk have poorer prognosis Pre-existing nervus Skin colour

35. Pathological indicators Tumour thickness( Breslow stage) Ulceration Nodular, acral lentiginous and genital melanomas Level on invasion ( clarks level) Size of tumour :< 2cm good prognosis Type of melanoma: leningo maligna best, nodular worst prognosis

36. SURVIVAL RATES FOR MALIGNANT MELANOMA BY STAGE • STAGE • 5Y (%) • 1OY(%) Stage lA 97 95 Stage 1B 92 86 Stage IIA 81 67 Stage II B 70 57 Stage IIC 53 40 Stage IIIA 78 59 Stage III B 59 43 Stage IIIC 40 24 Stage IV 15 10 Data n:ttapolated from Edge SB, Byrd DR, Compton CC, et al., eels. AJCC c:-cn St~agmg ~. 7th edn . New York, NY: Springer; 2010.

37. Conclusion Early detection is very important in curing malignant melanoma unfortunately patients in our environment present late believing there lesion is not medical Even those who present early still believe excision is not a cure which has made it a serious public health problem. Public enlightenment will increase awareness of the disease and its prevention This will lead to a decrease incidence rate, morbidity and mortality while increasing prognosis.

38. References Grabb And Smith's Plastic Surgery Seventh Edition Principles and practice of surgery including pathology in the tropics 4 th edition Edge SB, Byrd DR, Compton CC, et al., eels. AJCC Cancer Staging manual. 7th edn . New York, NY: Springer; 2010.

39. Thank you