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Melanoma
ByDr Abeer Elsayed Aly
Lecturer of medical oncologySECI
19/03/2013
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Melanoma Incidence and Mortality
• Incidence (US)–59,580 new cases
• 33,580 new male cases • 26,000 new female cases• 12 per 100,000 population
• Mortality (US)–7,770 total
• 4,910 males• 2,860 females
American Cancer Society, Cancer Facts and Figures. 2005.
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Melanoma: risk factors
• Constitutional predisposition– Fair skin/hair color/ freckling– Burn vs tan– >20 benign nevi (moles) or >3 atypical nevi– Family history of dysplastic nevi– Increasing age– Immunosuppression– Xeroderma pigmentosum– H/O solar keratosis, squamous cell carcinoma
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Melanoma: risk factors
• Risk behaviors– >3 sunburns– Episodic excessive
sunlight exposure– Long term
continuous sunlight exposure
– UV exposure at tanning salons
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Melanoma
The challenge (historically):– Early detection– Rapid growth/high
proliferation rate – Chemotherapy resistant– Radiation resistant– Short anticipated
survival
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Types of Melanoma
• Acral lentiginous• Mucosal melanoma• Superfical spreading melanoma• Lentigo maligna melanoma• Nodular melanoma
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Superficial spreading
• most common head and neck, 50%• 4th to 5th decade• clinical mixture of brown/tan, pink/white
irregular borders, biphasic growth• irregular nests in epidermis • underlying lymphoid infiltrate• enlarged nests and single cells in all epidermal
layers
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Lentigo maligna
• 20% of head and neck• longest radial growth phase >15 yrs• elderly sun exposed areas• clinical dark, irregular ink spot• contiguous lintiginous proliferation, dyshesive,
variable shape, atrophic epidermis, infundibular basal cell layer of hair follicles
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Lentigo maligna
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Nodular melanoma
• 30% of head and neck• 5th decade• aggressive monophasic growth• sun-exposed and nonexposed areas• well circumscribed blue/black or nodular with
involution in irregular plaque• downward tumorigenic growth, expand
papillary dermis into reticular dermis
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Nodular melanoma
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Mucosal melanoma
• 8% head and neck• histologic staging little use• local control predicts survival• neck dissection for clinical N+• XRT for histo N+• adjuvant interferon alpha 2-b
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Biopsy techniques
• Excisional biopsy 1-3 mm marginsavoid wider margins (accurate lymphatic mapping)
• Full thickness incisional/punch biopsy for large lesionslesions of the palms, soles, digits, face, ears
• Deep shave biopsiesWhen suspicion for melanoma is low
NCCN Guidelines 2005
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Staging system
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Clark staging
• Based upon histologic level of invasion• Level I – Epidermis only (in situ)
• Level II – Invades the papillary dermis, but not to the papillary-reticular interface
• Level III – Invades to the papillary-reticular interface, but not into the reticular dermis
• Level IV – Into the reticular dermis
• Level V – Into subcutaneous tissue
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Breslow staging
• Based upon absolute depth of invasion• Stage I – < 0.75 mm• Stage II – 0.76 – 1.5 mm• Stage III – 1.51 – 4.0 mm• Stage IV - > 4.0 mm
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Work up• Labs
– LDH• Radiology
– CXR– Possible CT for metastasis– Possible CT abdomen, MRI brain– Possible Lymphoscintigraphy
• Excision– 2 cm margins
• Adjunctive Therapy– Possible elective neck dissection– Possible sentinel lymph node biopsy– Possible elective radiation
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Prognostic indicators
• Thickness (Breslow depth)• Nodal status• Ulceration• Mitosis• Satellite lesions• In transit lesions
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Prognostic indicators
• Thickness (Breslow depth)• Nodal status• Ulceration• Mitosis• Satellite lesions• In transit lesions
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Prognostic indicators
• Thickness (Breslow depth)• Nodal status• Ulceration• Mitosis• Satellite lesions• In transit lesions
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Prognostic Indicators: Nodal status
• OS for patients with 1 positive sentinel node is 60% at 5 years
• OS for patients with a single palpable node is 40% at 5 years
• Gershenwald et al, 2001
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Prognostic indicators
• Thickness (Breslow depth)• Nodal status• Ulceration• Mitosis• Satellite lesions• In transit lesions
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Mitotic Index
• N = 3661 from the Sydney Melanoma Database• Correlated
– clinical information (survival)– primary tumor thickness (Breslow depth)– ulcerative state (infiltrative, attenuative, and traumatic)– tumor mitotic rate (TMR) (at the invading front, deep border)
• Conclusion: TMR is a more powerful prognostic indicator than ulceration in patients with primary cutaneous melanoma
Azzola et al, Cancer 2003
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Prognostic indicators
• Thickness (Breslow depth)• Nodal status• Ulceration• Mitosis• Satellite lesions• In transit lesions
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Risk of In-Transit Metastasis
• In- transit metastasis– Cutaneous / subcutaneous tissue– Between the primary tumor – and the draining lymph node basin
• 5 yr survival rates: 12% - 37%• Risk factors:
– Thicker primary– Lower extremity– Regional LN metastasis
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Other prognostic factors:
• LDH– Elevated levels correlate with:
Early recurrenceShorter survival (Newcki et al, 2008)
• Serum S100 level– Early studies suggest:
Shorter survivalEarly distant relapsePoorer response to treatment (Smith et al, 2008)
• Microvessel Density
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Other prognostic factors:
• LDH– Elevated levels correlate with:
Early recurrenceShorter survival (Newcki et al, 2008)
• Serum S100 level– Early studies suggest:
Shorter survivalEarly distant relapsePoorer response to treatment (Smith et al, 2008)
• Microvessel Density
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Other prognostic factors:
•LDH– Elevated levels correlate with:
Early recurrenceShorter survival (Newcki et al, 2008)
• Serum S100 level– Early studies suggest:
Shorter survivalEarly distant relapsePoorer response to treatment (Smith et al, 2008)
• Microvessel Density
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Adjuvant treatment
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Metastatic Melanoma
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Dendritic cell
T cell
MHC
B7
TCR
CD28
Antigen
CTLA4
Blocking Antibodies to CTLA4
Leach DR, et al. Science 1996;271:1734-1736.
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Vaccine
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Phase I GVAX: Melanoma
Vax DTH
Met Vasculopathy
Pre Met
CD4 CD8
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Adaptive Immune Therapy
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BRAF Inhibitor
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