Management of malignant melanoma

An account on management of malignant melanoma

1. 45 Yr old female with a biopsy proven melanoma in the left heel. Discuss the management? Dr. W. G. P. Kanchana Registrar in Surgery

2. Management Plan History Examination Investigations Imaging Staging Treatment Local Regional Systemic Follow-up Recurrences

3. Introduction The Incidence of melanoma continue to increase dramatically. Life time risk of developing cutaneous melanoma in women is 1 in 34, in men 1 in 53. Melanoma incidence increases in men more rapidly than any other malignancy. In women increase in numbers second only to lung cancers. Median age at diagnosis is 59 years.

4. Introduction Tumour of melanocyte origin. It is responsible for 80% of deaths due to skin cancer. Clarks model of progression

5. Risk Factors

6. Classification Superficial Spreading Melanoma Lentigo- Maligna Melanoma Nodular Melanoma Acral -Lentiginous Melanoma A D C B

7. Acral -Lentiginous Melanoma Occurs in areas not excessively exposed to sunlight and where hair follicles are absent Found on the palms of the hands, soles, in nail beds, and mucous membranes in dark-skinned people Appears as an irregular pigmented macule that develops nodules Becomes invasive early

8. Superficial Spreading Melanoma Most common form; usually affects middle-aged people, occurs most frequently on trunk and lower extremities. Circular lesions with irregular outer portions. Margins of lesion flat or elevated and palpable. May appear in combination of colors, with hues of tan, brown, and black mixed with gray, bluish black, or white; sometimes a dull, pink-rose color is noted in a small area within the lesion.

9. Lentigo- Maligna Melanoma Slowly evolving pigmented lesion Occurs on exposed skin areas; hand, head, and neck in elderly people First appears as tan, flat lesion, which in time undergoes changes in size and color

10. Nodular Melanoma Spherical, blueberry-like nodule with relatively smooth surface and uniform blue-black color May be dome-shaped with a smooth surface or have other shadings of red, gray, or purple May appear as irregularly shaped plaques May be described as a blood blister that fails to resolve Invades directly into adjacent dermis (vertical growth); poor prognosis

11. Common Sites

12. History Cont.. DM, History of Smoking, Peripheral vascular disease Cardio-Respiratory Fitness (IHD, BA, COPD) Drug History

13. Examination Primary Lesion Satellite Lesions Smaller lesions with-in 2cm from the primary lesion. In-transit Lesions Lesions >2cm away from the primary tumour in the direction of the draining LN basin. Draining LN basin Complete Skin Examination

14. Examination Systemic Examination Chest Abdomen Pelvis Other LN groups Assessment for Fitness for Anaesthesia and Surgery.

15. Biopsy Excisional Biopsy (elliptical, punch or saucerization / deep shave) with 1 – 3 mm margins preferred. Avoid wider margins to permit accurate subsequent lymphatic mapping . Orientation of the biopsy should be planned with the definitive wide excision in mind. ( Parallel to lymphatics ). Full-thickness incisional or punch biopsy of clinically thickest portion of the lesion acceptable in certain anatomic areas (palm/sole, digit, face, ear). Superficial shave biopsy may compromise pathological diagnosis and assessment of Breslow thickness . (lesions with low index of suspicion)

16. Breslow thickness Prognostic significance of depth of invasion by the tumour was first reported by Alexander Breslow (Pathologist) in 1970. Breslow thickness is one of the cornerstones of current AJCC TNM staging system.

17. Clarks Level Describes the level of anatomical invasion by the tumour in skin. It has lower predictive value, less reproducible and more operator dependent. Level 1 : Melanoma confined to the epidermis (melanoma in situ) Level 2 : Invasion into the papillary dermis Level 3 : Invasion to the junction of the papillary and reticular dermis Level 4 : Invasion into the reticular dermis Level 5 : Invasion into the subcutaneous fat It has a prognostic significance only in tumours <1mm Breslow depth.

18. Investigations Imaging USS regional LNs CT Chest, Abdomen, Pelvis Whole body FDG PET/CT MRI of Brain Biochemical Serum LDH

19. Staging T Stage -> Biopsy Report

20. N Staging Micrometastases are diagnosed after sentinel node biopsy and completion lymphadenectomy. Macrometastases are defined as clinically detectable nodal metastases confirmed by therapeutic lymphadenectomy or when nodal metastasis exhibits gross extracapsular extension.

21. M Staging

22. Clinical Staging / Prognostic groups Based on TNM staging, patients are categorized into clinical stages / Prognostic groups

23. Principles of Imaging Imaging to evaluate specific signs and symptoms suggestive of possible metastasis is recommended in all stages. Stage specific routine investigations. Stage 0, IA, IB, II Routine Imaging not recommended. Stage I/II -> Consider nodal basin USS prior to SLNB for patients with equivocal regional LN physical examination. USS not a substitute for SLNB

24. Principles of Imaging Stage III (Clinically + ve nodes / + ve SLNB, Clinical or microscopic satellite lesions, intransit lesions) , Stage IV Imaging for baseline staging. At a minimum, Pelvis CT in the setting of inguinofemoral lymphadenopathy to rule out associated pelvic or retroperitoneal lymphadenopathy. Baseline brain MRI in patients with stage IIIC or stage IV

25. Treatment – Stage 0, I Pathologic stage 0 or Stage IA patients do not require pathologic evaluation of their LNs.

26. Treatment – Stage IB, II

27. Treatment - Stage III

28. Stage III – Satellite lesions & In-transit lesions

29. Treatment - Stage IV

30. Wide Local Excision Margins may be modified to accommodate individual anatomic and functional considerations

31. Reconstructive Procedures Skin Grafting Local Tissue Transfer Medial plantar flap Reverse sural neurocutaneous island flap Lateral supramalleolar flap Free Tissue Transfer

32. LIU et al:, Limb salvage surgery following resection of a melanoma: Foot and ankle reconstruction using cutaneous flaps, ONCOLOGY LETTERS 8: 1966-1972, 2014

33. Sentinel Node Biopsy - SLNB For further risk stratification of Stage I – II patients. Most important prognostic factor in lesions >1mm thickness according to recent large multicenter RCT (MSLT – 1 trial). 5% - 40% patients will be upstaged from stage I/II to III. Low rates of + ve SLNB for patients with lesions <1mm thickness. Significance of SLNB in this group of patients is unclear. Technique include perilesional injection of methylene blue / isosulfan blue and radiolabeled dye and intra-operative detection visually and using gamma camara .

34. Complete LN dissection

35. Pathological Staging Pathological staging includes micro-staging of the primary melanoma and pathologic information about the regional LNs after partial or complete lymphadenectomy. Pathologic stage 0 or Stage IA patients are the exception, they do not require pathologic evaluation of their LNs.

36. RT for melanoma

37. Systemic Therapy for unresectable disease

38. Follow-up Common follow-up recommendations for All Patients At least annual skin examination for life. Educate patient in regular self skin and LN exam. Regional LN USS for patients with equivocal LN exam. Patients who did not undergo SLNB, Patient who did not undergo complete LN dissection. -> LN USS every 3 – 12 months for 1 st 2 – 3 years after diagnosis. Follow-up schedule influenced by risk of recurrence, prior primary melanoma, family Hx , risk of nodal recurrence. Referral to genetic counselor for p16/CDKN2A mutation testing in presence of 3 or more invasive melanoma or mix of invasive melanoma and pancreatic cancer in an individual or family.

39. Follow-up

40. Follow-up

41. Thank You !