MELANOMA
Melanoma
Melanoma
• Represents 4% of all
cancers
• Most common malignancy
in women aged 25-29.
• Incidence is rising faster
than any other cancer
• Lifetime risk of developing
melanoma now about 1 in
70
• 30% arise in existing nevi
Risk Factors
• Fair skin
• Presence of atypical nevi
• Personal history of melanoma
• Family history of atypical nevi or melanoma
• History of blistering sunburn
• Congenital nevi (incidence increases with increasing
size)
ABCDs of Melanoma
Recognition
• Asymmetry - one half of lesion does not look like
the other
• Borders - Scalloped border or focal extension into
surrounding skin
• Color variegation - varying hues and colors (black,
brown, red, blue and white
• Diameter - >6mm
Superficial Spreading
Melanoma
• Most common subtype
accounting for 70-80% of
melanomas
• F > M mostly Caucasians
• Most often on trunk and
extremities
• Tend to be > 6mm
• Spread laterally for years
before developing nodules
Nodular Melanoma
• Account for 10-15%
of melanomas
• M=F
• Most often found on
the extremities
• Evolve over months
and extend vertically
with little lateral
spread
Lentigo Maligna and Lentigo
Maligna Melanoma
• Account for 5-10% of
melanomas
• Arise most often on the
face, neck or dorsal arms
in older Caucasians
• M = F. Develop over
years or decades
• Lentigo Maligna
represents in situ lesion
and 5% progress to
invasive LMM
Amelanotic Melanoma
• Descriptive term for nonpigmented melanoma
• Any type can be
amelanotic
• 2% of all melanomas are
amelanotic
• Malignant cells produce
little or no pigment
• Poorer prognosis due to
delayed diagnosis
Acral Lentiginous Melanoma
• Accounts for 7% of
melanomas
• Occurs on hands, feet, nails
and mucous membranes
• Most common melanoma
in blacks and asians > 50%
• Least common in
Caucasians
• Leading cause of skin
cancer deaths
Acral Lentiginous Melanoma
• Most patients are between
60 -70
• Usually slow growing
• Often difficult to detect
early which leads to poor
prognosis
• Often begins as a
brown/black streak under a
nail or bruise like area on
acral skin
Acral Lentiginous Melanoma
• Diagnosis is by clinical
suspicion and tissue biopsy
• Treatment is surgical
excision with appropriate
margins and in some cases
requires amputation
• Additional studies(PET,
CT, SNL) are performed if
indicated
Workup
• All suspicious lesions should be biopsied. This does
not increase the risk of metastases.
• Excisional or punch biopsy allows for accurate
measurement of Breslow’s depth. Never shave
biopsy a suspected melanoma.
• Breslow’s depth, ulceration and mitotic rate are most
important features histologically
• Sentinel lymph node biopsy should be done on all
melanomas >=1mm
• For patients with positive sentinel nodes, PET/CT
scanning should be performed to rule out distant
metastases
Treatment
• Wide local excision with adequate margins is treatment of
choice
• Appropriate margin is determined by Breslow’s depth
• Melanoma in situ requires a margin of 0.5 cm
• Melanoma up to 2.0 mm requires a 1.0 cm margin with full
thickness dermis and subcutaneous fat
• Melanoma > 2.0 mm requires a 2.0 cm margin with full
thickness dermis and subcutaneous fat
Sentinel Node Biopsy
• Lymphoscintigraphy procedure where a sulfur colloid
tagged with technetium-99m is injected at the site of the
initial tumor and followed to the draining lymph node
basin
• 15 minutes prior to dissection blue dye is injected at the
same site.
• The nodal basin is then dissected and inspected for those
nodes that take up the dye and are shown by Geiger
counter to have taken up the radioactive material. These
are the sentinel node(s)
Sentinel Nodes
• Once identified the sentinel nodes are removed and
examined histologically for evidence of tumor spread
• If sentinel nodes are positive full elective lymph node
dissection may be done as well as further staging workup
• If sentinel node(s) is negative no further workup is
required
Adjuvant Therapy
• ELND has shown no real increase in survival
• Adjuvant therapy with interferon was often
recommended for those with advance stages of
disease but did not significantly increase survival
• Interferon has numerous side effects (flu like
symptoms) making it difficult to complete treatment
Adjuvant Therapy
• Zelboraf (vemurafenib) - For patients with
metastatic melanoma with tumors that express
a gene mutation called BRAF V600E.
• BRAF helps regulate cell growth. The variant
of BRAF targeted by Zelboraf is a gene
mutation that allows melanoma cancer cells to
spread
• Almost 50 percent of all melanoma tumors
have the BRAF genetic mutation
• Not yet clear how long Zelboraf can increase
melanoma survival.
Adjuvant Therapy
• Yervoy (ipilimumab) - For the treatment of
late-stage, metastatic melanoma
• Patients taking Yervoy survived an average of
10 months after starting treatment
• A monoclonal antibody that blocks a crucial
switch on immune cells called CTLA-4.
Cancers use this switch to turn off the body's
anticancer immune responses.
• Nearly 13% of patients taking Yervoy had
severe or fatal autoimmune reactions.
Melanoma Survival
• Stage IA: The 5-year survival rate is around 97%. The 10year survival is around 95%.
• Stage IB: The 5-year survival rate is around 92%. The 10year survival is around 86%.
• Stage IIA: The 5-year survival rate is around 81%. The 10year survival is around 67%.
• Stage IIB: The 5-year survival rate is around 70%. The 10year survival is around 57%.
• Stage IIC: The 5-year survival rate is around 53%. The 10year survival is around 40%.
Melanoma Survival
• Stage IIIA: The 5-year survival rate is around
78%. The 10-year survival is around 68%.
• Stage IIIB: The 5-year survival rate is around
59%. The 10-year survival is around 43%.
• Stage IIIC: The 5-year survival rate is around
40%. The 10-year survival is around 24%.
• Stage IV: The 5-year survival rate for stage IV
melanoma is about 15% to 20%. The 10-year
survival is about 10% to 15%.
Prevention
• Wear protective clothing
• Always use sunscreen SPF 30 - 45. Must block both
UVA and UVB
QuickTime™and a
TIFF(Uncompressed) decompressor
are needed to see this pi cture.
• Avoid midday sun 10 am - 3 pm
• Self skin exams
• Avoid sunburn
Follow Up
• All melanoma patients should have semiannual skin examinations including lymph
node assessment for 2-3 years followed by
annual exams for their lifetime
• Appropriate scanning should continue as
indicated
• All first degree relatives should have a
baseline skin exam and annual exams for life