melanoma
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Malignant MelanomaMalignant MelanomaDr Foroogh MousaviDr Foroogh Mousavi
What is melanomaWhat is melanoma
Skin malignancy that is the result of Skin malignancy that is the result of uncontrolled multiplication of melanocytes.uncontrolled multiplication of melanocytes.
Melanocytes are a group of cells in the Melanocytes are a group of cells in the superficial layer of the skin that produce superficial layer of the skin that produce melanin ( a dark pigment) as a response to melanin ( a dark pigment) as a response to ultraviolet light.ultraviolet light.
Other forms: ocular , visceral Other forms: ocular , visceral
Etiology Etiology
Genetics : p16,p19,ras.Genetics : p16,p19,ras.
UV exposure , by various mechanisms UV exposure , by various mechanisms including damaging melanocytes DNA.including damaging melanocytes DNA.
Sunburn : intermittent, blistering sunburns.Sunburn : intermittent, blistering sunburns.
Warning signs: changing moles, positive Warning signs: changing moles, positive family history, previous history of melanomafamily history, previous history of melanoma
EpidemiologyEpidemiology
Highest incidence rate in Highest incidence rate in Queensland ,Australia: 57 per100,000.Queensland ,Australia: 57 per100,000.
Rapid increase in incidence worldwide, only Rapid increase in incidence worldwide, only second to lung cancer. Risk: 1 in 1500 in second to lung cancer. Risk: 1 in 1500 in 1935 , 1 in 75 in 2000.1935 , 1 in 75 in 2000.
Gender demographics :M>FGender demographics :M>F
Average age of diagnosis : 57 yrs, rare in <10 Average age of diagnosis : 57 yrs, rare in <10 yrs.yrs.
DiagnosisDiagnosis
Clinical: checking suspicious lesion , ABCD.Clinical: checking suspicious lesion , ABCD.
Pathology/biopsy : confirms diagnosisPathology/biopsy : confirms diagnosis
Imaging: staging and spreadImaging: staging and spread
Staging Staging
According to skin layers involved ( Clarke):According to skin layers involved ( Clarke): Level I : epidermis, Level II to IV : dermis, Level Level I : epidermis, Level II to IV : dermis, Level
V: subcutaneous fatV: subcutaneous fat
According to depth (Breslow): 0.75 mm, 0.76-According to depth (Breslow): 0.75 mm, 0.76-1.5, 1.51-4mm, > 4mm.1.5, 1.51-4mm, > 4mm.
TNM :Thickness and ulceration, Nodes , TNM :Thickness and ulceration, Nodes , MetastasisMetastasis
Nodal assessmentNodal assessment
Sentinel node biopsy : Sentinel node biopsy : Indicated if >1mm thick Indicated if >1mm thick Sentinel node : the very first draining lymph nodeSentinel node : the very first draining lymph node Blue dye or Tc radioisotopeBlue dye or Tc radioisotope
Melanoma on medical Melanoma on medical imagingimaging
Chest radiograph : Chest radiograph :
-Routinely obtained on diagnosis -Routinely obtained on diagnosis
-Usually negative on stage I and II: usually -Usually negative on stage I and II: usually negative , provides a baseline for future negative , provides a baseline for future comparison.comparison.
- Important to obtain in stage III and higher : - Important to obtain in stage III and higher : first metastatic site are lungs.first metastatic site are lungs.
Melanoma on medical Melanoma on medical imagingimaging
CT CT Head : brain mets assessmentHead : brain mets assessment Chest: indicated in stage IV disease to detect Chest: indicated in stage IV disease to detect
asymptomatic metsasymptomatic mets Abdomen : stage III, in-transit and locally Abdomen : stage III, in-transit and locally
recurrent recurrent
usually low yield but provide a base line.usually low yield but provide a base line. Pelvis : only when primary region is below the Pelvis : only when primary region is below the
waistwaist
58 year old female who developed left-handed weakness. A. Non-contrast melanoma on CT, usually has a hemorrhagic appearance. B. Contrast enhanced CT , mets show contrast enhancement due to destruction of blood-brain barrier.
AA B
Medical imagingMedical imaging
MRI : brain MRI : brain
Only in case of known mets or symptomatic Only in case of known mets or symptomatic patients.patients.
A 55 yr female with melanoma of right leg and hemorrhagic metastasis to the brain. T1: large hyperintense lesion left posterior parietal lobe. Increased conspicuity of smaller lesions on post-Gad.
Melanoma on medical Melanoma on medical imaging imaging
PET : PET :
Indicated for staging of known nodal disease, Indicated for staging of known nodal disease, in-transit diseasein-transit disease
Therapy responseTherapy response
Pre-operative assessment ( excluding mets)Pre-operative assessment ( excluding mets)
AB
82 year old male with right knee melanoma. A.Initial PET scan showing intensely FDG right knee lesion.B. progressive disease , cutaneous , subcutaneous and intramuscular mets.
67 year old male with resected lip, shoulder and scalp melanoma.
Also confirmed duodenojejunal junction melanoma. Brain mets found on staging PET
Course and prognosisCourse and prognosis
Curable if detected early. Usual presentations are Curable if detected early. Usual presentations are on extreme ends of spectrum. on extreme ends of spectrum.
Depends on :Thickness, ulceration, nodal Depends on :Thickness, ulceration, nodal involvement, metastasis.involvement, metastasis.
If up to 1mm thick , no ulceration and no nodal If up to 1mm thick , no ulceration and no nodal involvement : 95 %, 5 year survival .involvement : 95 %, 5 year survival .
If 4 mm and ulcerated: 45% 5yr survival If 4 mm and ulcerated: 45% 5yr survival
If ulcerated lesion & positive node: 24-29%If ulcerated lesion & positive node: 24-29%
Lung mets : 7% , 5 yr survival Lung mets : 7% , 5 yr survival
TreatmentTreatment
Surgery : wide local excision, Sentile node Surgery : wide local excision, Sentile node excision, brain mets ( symptomatic ) excision, brain mets ( symptomatic )
ChemotherapyChemotherapy
RadiotherapyRadiotherapy
References References
emedicine.comemedicine.com
Radiopedia.orgRadiopedia.org
Dermnetnz.orgDermnetnz.org
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