melanoma anal canal
TRANSCRIPT
MELANOMA-ANAL CANALDrAJoseph Stalin Mch PG
PROFDRRRAJARAMANrsquoS UNITDEPT OF SURGICAL ONCOLOGYGOVT ROYAPETTAH HOSPITAL
CHENNAI
CONTENTS
bull Anal Mucosal Melanoma
- Introduction
- Clinical presentation
- Diagnosis
- Treatment
Take home message
INTRODUCTION
bull Anal melanoma - 05 to 2 - anal malignancies
bull Less than 2 of all melanomas
bull The third most common melanoma after the cutaneous and ocular varieties
bull Most common site for primary gastrointestinal melanoma
ETIOLOGY
bull No known risk factors
bull Risk factors for cutaneous melanoma like nevus sunlight exposure does not predispose to anal melanoma
PATHOLOGY
bull Melanoma arises from melanocytes derived from neural crest cells
bull Melanocytes subjected to carcinogenic stimuli undergo malignant transformation
bull Carcinogenic stimuli in anal melanoma unknown
bull Subsets of anal melanoma shows mutation in BRAF Ckit p53 mutation
Symptoms
bull Bleeding per rectum ndashmost common (50-60)
bull Perianal itching and irritation (15-20)
bull mass protruding through anus
bull perianal discharge
CLINICAL PRESENTATION
bull More common in women
bull Mean age 70 yrs(29-91)
bull Distant metastasis seen in 30 of people at diagnosis
SPREAD
bull Lymphatic Spread Inguinal amp mesorectalnodes
bull Systemic LungLiverBrain Bone
DIAGNOSIS
bull Diagnosis can be made with visual inspection and anoscopy
bull commonly present as polypoidal mass
bull Distance from anal verge and mobility assessed
bull Clinically evident pigmented leision only in 20 of casesIn others pigmentation is obscured
bull 20 are amelanotic histologically
THROMBOSED PILE LIKE MASSS
Polypoidal lesion in colonoscopy
DIFFERENTIAL DIAGNOSIS
Anal carcinomalymphoma
Perianal haematoma
Thrombosed haemorrhoids
Anal or Rectal Polyp
INVESTIGATIONS
bull PROCTOSCOPY amp BIOPSY
bull USG ABDOMENPELVIS
bull ENDOLUMINAL USG
bull PET
USG abdomenpelvis to ro liver mets
ENDOLUMINAL USG Depth of invasion and nodal status
ROLE OF PET CT
bull Positron emission tomography (PET) may be helpful for staging of anorectal melanoma
bull The sensitivity was 74 to 100 and specificity 67 to 100
IMMUNOHISTOCHEMISTRY
Melanoma panel of markersS-100 proteinVimentinMelan-A
HMB-45To Ro other diseaseCytokeratins (Pagetrsquos disease) CD45 (lymphoma)
chromogranin and synaptophysin (undifferen-tiated carcinoma) CD34 (GIST) and Desmin and caldesmon (sarcoma)
STAGING
bull The staging of anal melanoma differs from that of cutaneous melanoma( based on Breslowclassification)
bull Anal melanoma is staged on a clinical basis focusing on locoregional and distant spread
( Clinics of Colorectal surgery vol19 Ross etal )
bull Stage I is local disease
bull stage II is local disease with regional lymph nodes
bull stage III is distant metastatic disease
STAGE I amp II
bull Surgical excision is the treatment of choice
bull Melanoma is highly resistant to RT Chemo No role either as defnitive treatment or as adjuvant therapy
SURGERY
bull WIDE LOCAL EXCISION ABDOMINO PERINEAL RESECTION for Stage III disease
bull Wide local excision (R0 resection ) is preferred
WIDE LOCAL EXCISION
bull Loan star retractor preferred
bull 1 cm margin(R0 resection)
bull TEMS for localised leision in rectum
APR
bull When anal sphinter is involved or R0 resection mandates sphinter excision APR indicated in stage Iamp II
bull No survival advantage for APR when compared to wide local excision
STUDIES
bull Droesh et al -2005
bull 301 pt
bull 172-APR129- WLE
bull Mean survival same for both
bull A comparison of wide local excision with abdominoperineal resection in anorectal melanoma
bull Yap LB1 Neary P
bull Seventeen large case series from over the past 10 years were reviewed
bull Comparison of the survival of patients who underwent APR with those who underwent WLE showed no statistically significant advantage for either procedure in patients at all disease stages
bull APR should therefore only be performed when local excision is not possible or for palliative purposes
Role of lymph node dissection
bull Lymph node dissection ndash inguinalmesorectal-does not confer survival advantage although it improves locoregional control
bull Bollo et al(23 patients )
bull Moozar et al (14 patients )
bull Brady et al(retrospective analysis )
STAGE III
bull Systemic chemotherapy
bull Drugs used are akin to cutaneous melanoma
bull Commonly used drugs
Dacarbazine
Temozolamide
TARGETED THERAPY
bull cKIT BRAF mutation seen in some subgroup
bull Targeted therapy ndashcKIT ( Imatinib) BRAF (Verufunamib) in adjuvant and metastatic setting shows good response in phase II trial
bull Yeh et al Interim analysis shows median survival improves by 3-5 months
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
CONTENTS
bull Anal Mucosal Melanoma
- Introduction
- Clinical presentation
- Diagnosis
- Treatment
Take home message
INTRODUCTION
bull Anal melanoma - 05 to 2 - anal malignancies
bull Less than 2 of all melanomas
bull The third most common melanoma after the cutaneous and ocular varieties
bull Most common site for primary gastrointestinal melanoma
ETIOLOGY
bull No known risk factors
bull Risk factors for cutaneous melanoma like nevus sunlight exposure does not predispose to anal melanoma
PATHOLOGY
bull Melanoma arises from melanocytes derived from neural crest cells
bull Melanocytes subjected to carcinogenic stimuli undergo malignant transformation
bull Carcinogenic stimuli in anal melanoma unknown
bull Subsets of anal melanoma shows mutation in BRAF Ckit p53 mutation
Symptoms
bull Bleeding per rectum ndashmost common (50-60)
bull Perianal itching and irritation (15-20)
bull mass protruding through anus
bull perianal discharge
CLINICAL PRESENTATION
bull More common in women
bull Mean age 70 yrs(29-91)
bull Distant metastasis seen in 30 of people at diagnosis
SPREAD
bull Lymphatic Spread Inguinal amp mesorectalnodes
bull Systemic LungLiverBrain Bone
DIAGNOSIS
bull Diagnosis can be made with visual inspection and anoscopy
bull commonly present as polypoidal mass
bull Distance from anal verge and mobility assessed
bull Clinically evident pigmented leision only in 20 of casesIn others pigmentation is obscured
bull 20 are amelanotic histologically
THROMBOSED PILE LIKE MASSS
Polypoidal lesion in colonoscopy
DIFFERENTIAL DIAGNOSIS
Anal carcinomalymphoma
Perianal haematoma
Thrombosed haemorrhoids
Anal or Rectal Polyp
INVESTIGATIONS
bull PROCTOSCOPY amp BIOPSY
bull USG ABDOMENPELVIS
bull ENDOLUMINAL USG
bull PET
USG abdomenpelvis to ro liver mets
ENDOLUMINAL USG Depth of invasion and nodal status
ROLE OF PET CT
bull Positron emission tomography (PET) may be helpful for staging of anorectal melanoma
bull The sensitivity was 74 to 100 and specificity 67 to 100
IMMUNOHISTOCHEMISTRY
Melanoma panel of markersS-100 proteinVimentinMelan-A
HMB-45To Ro other diseaseCytokeratins (Pagetrsquos disease) CD45 (lymphoma)
chromogranin and synaptophysin (undifferen-tiated carcinoma) CD34 (GIST) and Desmin and caldesmon (sarcoma)
STAGING
bull The staging of anal melanoma differs from that of cutaneous melanoma( based on Breslowclassification)
bull Anal melanoma is staged on a clinical basis focusing on locoregional and distant spread
( Clinics of Colorectal surgery vol19 Ross etal )
bull Stage I is local disease
bull stage II is local disease with regional lymph nodes
bull stage III is distant metastatic disease
STAGE I amp II
bull Surgical excision is the treatment of choice
bull Melanoma is highly resistant to RT Chemo No role either as defnitive treatment or as adjuvant therapy
SURGERY
bull WIDE LOCAL EXCISION ABDOMINO PERINEAL RESECTION for Stage III disease
bull Wide local excision (R0 resection ) is preferred
WIDE LOCAL EXCISION
bull Loan star retractor preferred
bull 1 cm margin(R0 resection)
bull TEMS for localised leision in rectum
APR
bull When anal sphinter is involved or R0 resection mandates sphinter excision APR indicated in stage Iamp II
bull No survival advantage for APR when compared to wide local excision
STUDIES
bull Droesh et al -2005
bull 301 pt
bull 172-APR129- WLE
bull Mean survival same for both
bull A comparison of wide local excision with abdominoperineal resection in anorectal melanoma
bull Yap LB1 Neary P
bull Seventeen large case series from over the past 10 years were reviewed
bull Comparison of the survival of patients who underwent APR with those who underwent WLE showed no statistically significant advantage for either procedure in patients at all disease stages
bull APR should therefore only be performed when local excision is not possible or for palliative purposes
Role of lymph node dissection
bull Lymph node dissection ndash inguinalmesorectal-does not confer survival advantage although it improves locoregional control
bull Bollo et al(23 patients )
bull Moozar et al (14 patients )
bull Brady et al(retrospective analysis )
STAGE III
bull Systemic chemotherapy
bull Drugs used are akin to cutaneous melanoma
bull Commonly used drugs
Dacarbazine
Temozolamide
TARGETED THERAPY
bull cKIT BRAF mutation seen in some subgroup
bull Targeted therapy ndashcKIT ( Imatinib) BRAF (Verufunamib) in adjuvant and metastatic setting shows good response in phase II trial
bull Yeh et al Interim analysis shows median survival improves by 3-5 months
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
INTRODUCTION
bull Anal melanoma - 05 to 2 - anal malignancies
bull Less than 2 of all melanomas
bull The third most common melanoma after the cutaneous and ocular varieties
bull Most common site for primary gastrointestinal melanoma
ETIOLOGY
bull No known risk factors
bull Risk factors for cutaneous melanoma like nevus sunlight exposure does not predispose to anal melanoma
PATHOLOGY
bull Melanoma arises from melanocytes derived from neural crest cells
bull Melanocytes subjected to carcinogenic stimuli undergo malignant transformation
bull Carcinogenic stimuli in anal melanoma unknown
bull Subsets of anal melanoma shows mutation in BRAF Ckit p53 mutation
Symptoms
bull Bleeding per rectum ndashmost common (50-60)
bull Perianal itching and irritation (15-20)
bull mass protruding through anus
bull perianal discharge
CLINICAL PRESENTATION
bull More common in women
bull Mean age 70 yrs(29-91)
bull Distant metastasis seen in 30 of people at diagnosis
SPREAD
bull Lymphatic Spread Inguinal amp mesorectalnodes
bull Systemic LungLiverBrain Bone
DIAGNOSIS
bull Diagnosis can be made with visual inspection and anoscopy
bull commonly present as polypoidal mass
bull Distance from anal verge and mobility assessed
bull Clinically evident pigmented leision only in 20 of casesIn others pigmentation is obscured
bull 20 are amelanotic histologically
THROMBOSED PILE LIKE MASSS
Polypoidal lesion in colonoscopy
DIFFERENTIAL DIAGNOSIS
Anal carcinomalymphoma
Perianal haematoma
Thrombosed haemorrhoids
Anal or Rectal Polyp
INVESTIGATIONS
bull PROCTOSCOPY amp BIOPSY
bull USG ABDOMENPELVIS
bull ENDOLUMINAL USG
bull PET
USG abdomenpelvis to ro liver mets
ENDOLUMINAL USG Depth of invasion and nodal status
ROLE OF PET CT
bull Positron emission tomography (PET) may be helpful for staging of anorectal melanoma
bull The sensitivity was 74 to 100 and specificity 67 to 100
IMMUNOHISTOCHEMISTRY
Melanoma panel of markersS-100 proteinVimentinMelan-A
HMB-45To Ro other diseaseCytokeratins (Pagetrsquos disease) CD45 (lymphoma)
chromogranin and synaptophysin (undifferen-tiated carcinoma) CD34 (GIST) and Desmin and caldesmon (sarcoma)
STAGING
bull The staging of anal melanoma differs from that of cutaneous melanoma( based on Breslowclassification)
bull Anal melanoma is staged on a clinical basis focusing on locoregional and distant spread
( Clinics of Colorectal surgery vol19 Ross etal )
bull Stage I is local disease
bull stage II is local disease with regional lymph nodes
bull stage III is distant metastatic disease
STAGE I amp II
bull Surgical excision is the treatment of choice
bull Melanoma is highly resistant to RT Chemo No role either as defnitive treatment or as adjuvant therapy
SURGERY
bull WIDE LOCAL EXCISION ABDOMINO PERINEAL RESECTION for Stage III disease
bull Wide local excision (R0 resection ) is preferred
WIDE LOCAL EXCISION
bull Loan star retractor preferred
bull 1 cm margin(R0 resection)
bull TEMS for localised leision in rectum
APR
bull When anal sphinter is involved or R0 resection mandates sphinter excision APR indicated in stage Iamp II
bull No survival advantage for APR when compared to wide local excision
STUDIES
bull Droesh et al -2005
bull 301 pt
bull 172-APR129- WLE
bull Mean survival same for both
bull A comparison of wide local excision with abdominoperineal resection in anorectal melanoma
bull Yap LB1 Neary P
bull Seventeen large case series from over the past 10 years were reviewed
bull Comparison of the survival of patients who underwent APR with those who underwent WLE showed no statistically significant advantage for either procedure in patients at all disease stages
bull APR should therefore only be performed when local excision is not possible or for palliative purposes
Role of lymph node dissection
bull Lymph node dissection ndash inguinalmesorectal-does not confer survival advantage although it improves locoregional control
bull Bollo et al(23 patients )
bull Moozar et al (14 patients )
bull Brady et al(retrospective analysis )
STAGE III
bull Systemic chemotherapy
bull Drugs used are akin to cutaneous melanoma
bull Commonly used drugs
Dacarbazine
Temozolamide
TARGETED THERAPY
bull cKIT BRAF mutation seen in some subgroup
bull Targeted therapy ndashcKIT ( Imatinib) BRAF (Verufunamib) in adjuvant and metastatic setting shows good response in phase II trial
bull Yeh et al Interim analysis shows median survival improves by 3-5 months
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
ETIOLOGY
bull No known risk factors
bull Risk factors for cutaneous melanoma like nevus sunlight exposure does not predispose to anal melanoma
PATHOLOGY
bull Melanoma arises from melanocytes derived from neural crest cells
bull Melanocytes subjected to carcinogenic stimuli undergo malignant transformation
bull Carcinogenic stimuli in anal melanoma unknown
bull Subsets of anal melanoma shows mutation in BRAF Ckit p53 mutation
Symptoms
bull Bleeding per rectum ndashmost common (50-60)
bull Perianal itching and irritation (15-20)
bull mass protruding through anus
bull perianal discharge
CLINICAL PRESENTATION
bull More common in women
bull Mean age 70 yrs(29-91)
bull Distant metastasis seen in 30 of people at diagnosis
SPREAD
bull Lymphatic Spread Inguinal amp mesorectalnodes
bull Systemic LungLiverBrain Bone
DIAGNOSIS
bull Diagnosis can be made with visual inspection and anoscopy
bull commonly present as polypoidal mass
bull Distance from anal verge and mobility assessed
bull Clinically evident pigmented leision only in 20 of casesIn others pigmentation is obscured
bull 20 are amelanotic histologically
THROMBOSED PILE LIKE MASSS
Polypoidal lesion in colonoscopy
DIFFERENTIAL DIAGNOSIS
Anal carcinomalymphoma
Perianal haematoma
Thrombosed haemorrhoids
Anal or Rectal Polyp
INVESTIGATIONS
bull PROCTOSCOPY amp BIOPSY
bull USG ABDOMENPELVIS
bull ENDOLUMINAL USG
bull PET
USG abdomenpelvis to ro liver mets
ENDOLUMINAL USG Depth of invasion and nodal status
ROLE OF PET CT
bull Positron emission tomography (PET) may be helpful for staging of anorectal melanoma
bull The sensitivity was 74 to 100 and specificity 67 to 100
IMMUNOHISTOCHEMISTRY
Melanoma panel of markersS-100 proteinVimentinMelan-A
HMB-45To Ro other diseaseCytokeratins (Pagetrsquos disease) CD45 (lymphoma)
chromogranin and synaptophysin (undifferen-tiated carcinoma) CD34 (GIST) and Desmin and caldesmon (sarcoma)
STAGING
bull The staging of anal melanoma differs from that of cutaneous melanoma( based on Breslowclassification)
bull Anal melanoma is staged on a clinical basis focusing on locoregional and distant spread
( Clinics of Colorectal surgery vol19 Ross etal )
bull Stage I is local disease
bull stage II is local disease with regional lymph nodes
bull stage III is distant metastatic disease
STAGE I amp II
bull Surgical excision is the treatment of choice
bull Melanoma is highly resistant to RT Chemo No role either as defnitive treatment or as adjuvant therapy
SURGERY
bull WIDE LOCAL EXCISION ABDOMINO PERINEAL RESECTION for Stage III disease
bull Wide local excision (R0 resection ) is preferred
WIDE LOCAL EXCISION
bull Loan star retractor preferred
bull 1 cm margin(R0 resection)
bull TEMS for localised leision in rectum
APR
bull When anal sphinter is involved or R0 resection mandates sphinter excision APR indicated in stage Iamp II
bull No survival advantage for APR when compared to wide local excision
STUDIES
bull Droesh et al -2005
bull 301 pt
bull 172-APR129- WLE
bull Mean survival same for both
bull A comparison of wide local excision with abdominoperineal resection in anorectal melanoma
bull Yap LB1 Neary P
bull Seventeen large case series from over the past 10 years were reviewed
bull Comparison of the survival of patients who underwent APR with those who underwent WLE showed no statistically significant advantage for either procedure in patients at all disease stages
bull APR should therefore only be performed when local excision is not possible or for palliative purposes
Role of lymph node dissection
bull Lymph node dissection ndash inguinalmesorectal-does not confer survival advantage although it improves locoregional control
bull Bollo et al(23 patients )
bull Moozar et al (14 patients )
bull Brady et al(retrospective analysis )
STAGE III
bull Systemic chemotherapy
bull Drugs used are akin to cutaneous melanoma
bull Commonly used drugs
Dacarbazine
Temozolamide
TARGETED THERAPY
bull cKIT BRAF mutation seen in some subgroup
bull Targeted therapy ndashcKIT ( Imatinib) BRAF (Verufunamib) in adjuvant and metastatic setting shows good response in phase II trial
bull Yeh et al Interim analysis shows median survival improves by 3-5 months
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
PATHOLOGY
bull Melanoma arises from melanocytes derived from neural crest cells
bull Melanocytes subjected to carcinogenic stimuli undergo malignant transformation
bull Carcinogenic stimuli in anal melanoma unknown
bull Subsets of anal melanoma shows mutation in BRAF Ckit p53 mutation
Symptoms
bull Bleeding per rectum ndashmost common (50-60)
bull Perianal itching and irritation (15-20)
bull mass protruding through anus
bull perianal discharge
CLINICAL PRESENTATION
bull More common in women
bull Mean age 70 yrs(29-91)
bull Distant metastasis seen in 30 of people at diagnosis
SPREAD
bull Lymphatic Spread Inguinal amp mesorectalnodes
bull Systemic LungLiverBrain Bone
DIAGNOSIS
bull Diagnosis can be made with visual inspection and anoscopy
bull commonly present as polypoidal mass
bull Distance from anal verge and mobility assessed
bull Clinically evident pigmented leision only in 20 of casesIn others pigmentation is obscured
bull 20 are amelanotic histologically
THROMBOSED PILE LIKE MASSS
Polypoidal lesion in colonoscopy
DIFFERENTIAL DIAGNOSIS
Anal carcinomalymphoma
Perianal haematoma
Thrombosed haemorrhoids
Anal or Rectal Polyp
INVESTIGATIONS
bull PROCTOSCOPY amp BIOPSY
bull USG ABDOMENPELVIS
bull ENDOLUMINAL USG
bull PET
USG abdomenpelvis to ro liver mets
ENDOLUMINAL USG Depth of invasion and nodal status
ROLE OF PET CT
bull Positron emission tomography (PET) may be helpful for staging of anorectal melanoma
bull The sensitivity was 74 to 100 and specificity 67 to 100
IMMUNOHISTOCHEMISTRY
Melanoma panel of markersS-100 proteinVimentinMelan-A
HMB-45To Ro other diseaseCytokeratins (Pagetrsquos disease) CD45 (lymphoma)
chromogranin and synaptophysin (undifferen-tiated carcinoma) CD34 (GIST) and Desmin and caldesmon (sarcoma)
STAGING
bull The staging of anal melanoma differs from that of cutaneous melanoma( based on Breslowclassification)
bull Anal melanoma is staged on a clinical basis focusing on locoregional and distant spread
( Clinics of Colorectal surgery vol19 Ross etal )
bull Stage I is local disease
bull stage II is local disease with regional lymph nodes
bull stage III is distant metastatic disease
STAGE I amp II
bull Surgical excision is the treatment of choice
bull Melanoma is highly resistant to RT Chemo No role either as defnitive treatment or as adjuvant therapy
SURGERY
bull WIDE LOCAL EXCISION ABDOMINO PERINEAL RESECTION for Stage III disease
bull Wide local excision (R0 resection ) is preferred
WIDE LOCAL EXCISION
bull Loan star retractor preferred
bull 1 cm margin(R0 resection)
bull TEMS for localised leision in rectum
APR
bull When anal sphinter is involved or R0 resection mandates sphinter excision APR indicated in stage Iamp II
bull No survival advantage for APR when compared to wide local excision
STUDIES
bull Droesh et al -2005
bull 301 pt
bull 172-APR129- WLE
bull Mean survival same for both
bull A comparison of wide local excision with abdominoperineal resection in anorectal melanoma
bull Yap LB1 Neary P
bull Seventeen large case series from over the past 10 years were reviewed
bull Comparison of the survival of patients who underwent APR with those who underwent WLE showed no statistically significant advantage for either procedure in patients at all disease stages
bull APR should therefore only be performed when local excision is not possible or for palliative purposes
Role of lymph node dissection
bull Lymph node dissection ndash inguinalmesorectal-does not confer survival advantage although it improves locoregional control
bull Bollo et al(23 patients )
bull Moozar et al (14 patients )
bull Brady et al(retrospective analysis )
STAGE III
bull Systemic chemotherapy
bull Drugs used are akin to cutaneous melanoma
bull Commonly used drugs
Dacarbazine
Temozolamide
TARGETED THERAPY
bull cKIT BRAF mutation seen in some subgroup
bull Targeted therapy ndashcKIT ( Imatinib) BRAF (Verufunamib) in adjuvant and metastatic setting shows good response in phase II trial
bull Yeh et al Interim analysis shows median survival improves by 3-5 months
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
Symptoms
bull Bleeding per rectum ndashmost common (50-60)
bull Perianal itching and irritation (15-20)
bull mass protruding through anus
bull perianal discharge
CLINICAL PRESENTATION
bull More common in women
bull Mean age 70 yrs(29-91)
bull Distant metastasis seen in 30 of people at diagnosis
SPREAD
bull Lymphatic Spread Inguinal amp mesorectalnodes
bull Systemic LungLiverBrain Bone
DIAGNOSIS
bull Diagnosis can be made with visual inspection and anoscopy
bull commonly present as polypoidal mass
bull Distance from anal verge and mobility assessed
bull Clinically evident pigmented leision only in 20 of casesIn others pigmentation is obscured
bull 20 are amelanotic histologically
THROMBOSED PILE LIKE MASSS
Polypoidal lesion in colonoscopy
DIFFERENTIAL DIAGNOSIS
Anal carcinomalymphoma
Perianal haematoma
Thrombosed haemorrhoids
Anal or Rectal Polyp
INVESTIGATIONS
bull PROCTOSCOPY amp BIOPSY
bull USG ABDOMENPELVIS
bull ENDOLUMINAL USG
bull PET
USG abdomenpelvis to ro liver mets
ENDOLUMINAL USG Depth of invasion and nodal status
ROLE OF PET CT
bull Positron emission tomography (PET) may be helpful for staging of anorectal melanoma
bull The sensitivity was 74 to 100 and specificity 67 to 100
IMMUNOHISTOCHEMISTRY
Melanoma panel of markersS-100 proteinVimentinMelan-A
HMB-45To Ro other diseaseCytokeratins (Pagetrsquos disease) CD45 (lymphoma)
chromogranin and synaptophysin (undifferen-tiated carcinoma) CD34 (GIST) and Desmin and caldesmon (sarcoma)
STAGING
bull The staging of anal melanoma differs from that of cutaneous melanoma( based on Breslowclassification)
bull Anal melanoma is staged on a clinical basis focusing on locoregional and distant spread
( Clinics of Colorectal surgery vol19 Ross etal )
bull Stage I is local disease
bull stage II is local disease with regional lymph nodes
bull stage III is distant metastatic disease
STAGE I amp II
bull Surgical excision is the treatment of choice
bull Melanoma is highly resistant to RT Chemo No role either as defnitive treatment or as adjuvant therapy
SURGERY
bull WIDE LOCAL EXCISION ABDOMINO PERINEAL RESECTION for Stage III disease
bull Wide local excision (R0 resection ) is preferred
WIDE LOCAL EXCISION
bull Loan star retractor preferred
bull 1 cm margin(R0 resection)
bull TEMS for localised leision in rectum
APR
bull When anal sphinter is involved or R0 resection mandates sphinter excision APR indicated in stage Iamp II
bull No survival advantage for APR when compared to wide local excision
STUDIES
bull Droesh et al -2005
bull 301 pt
bull 172-APR129- WLE
bull Mean survival same for both
bull A comparison of wide local excision with abdominoperineal resection in anorectal melanoma
bull Yap LB1 Neary P
bull Seventeen large case series from over the past 10 years were reviewed
bull Comparison of the survival of patients who underwent APR with those who underwent WLE showed no statistically significant advantage for either procedure in patients at all disease stages
bull APR should therefore only be performed when local excision is not possible or for palliative purposes
Role of lymph node dissection
bull Lymph node dissection ndash inguinalmesorectal-does not confer survival advantage although it improves locoregional control
bull Bollo et al(23 patients )
bull Moozar et al (14 patients )
bull Brady et al(retrospective analysis )
STAGE III
bull Systemic chemotherapy
bull Drugs used are akin to cutaneous melanoma
bull Commonly used drugs
Dacarbazine
Temozolamide
TARGETED THERAPY
bull cKIT BRAF mutation seen in some subgroup
bull Targeted therapy ndashcKIT ( Imatinib) BRAF (Verufunamib) in adjuvant and metastatic setting shows good response in phase II trial
bull Yeh et al Interim analysis shows median survival improves by 3-5 months
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
CLINICAL PRESENTATION
bull More common in women
bull Mean age 70 yrs(29-91)
bull Distant metastasis seen in 30 of people at diagnosis
SPREAD
bull Lymphatic Spread Inguinal amp mesorectalnodes
bull Systemic LungLiverBrain Bone
DIAGNOSIS
bull Diagnosis can be made with visual inspection and anoscopy
bull commonly present as polypoidal mass
bull Distance from anal verge and mobility assessed
bull Clinically evident pigmented leision only in 20 of casesIn others pigmentation is obscured
bull 20 are amelanotic histologically
THROMBOSED PILE LIKE MASSS
Polypoidal lesion in colonoscopy
DIFFERENTIAL DIAGNOSIS
Anal carcinomalymphoma
Perianal haematoma
Thrombosed haemorrhoids
Anal or Rectal Polyp
INVESTIGATIONS
bull PROCTOSCOPY amp BIOPSY
bull USG ABDOMENPELVIS
bull ENDOLUMINAL USG
bull PET
USG abdomenpelvis to ro liver mets
ENDOLUMINAL USG Depth of invasion and nodal status
ROLE OF PET CT
bull Positron emission tomography (PET) may be helpful for staging of anorectal melanoma
bull The sensitivity was 74 to 100 and specificity 67 to 100
IMMUNOHISTOCHEMISTRY
Melanoma panel of markersS-100 proteinVimentinMelan-A
HMB-45To Ro other diseaseCytokeratins (Pagetrsquos disease) CD45 (lymphoma)
chromogranin and synaptophysin (undifferen-tiated carcinoma) CD34 (GIST) and Desmin and caldesmon (sarcoma)
STAGING
bull The staging of anal melanoma differs from that of cutaneous melanoma( based on Breslowclassification)
bull Anal melanoma is staged on a clinical basis focusing on locoregional and distant spread
( Clinics of Colorectal surgery vol19 Ross etal )
bull Stage I is local disease
bull stage II is local disease with regional lymph nodes
bull stage III is distant metastatic disease
STAGE I amp II
bull Surgical excision is the treatment of choice
bull Melanoma is highly resistant to RT Chemo No role either as defnitive treatment or as adjuvant therapy
SURGERY
bull WIDE LOCAL EXCISION ABDOMINO PERINEAL RESECTION for Stage III disease
bull Wide local excision (R0 resection ) is preferred
WIDE LOCAL EXCISION
bull Loan star retractor preferred
bull 1 cm margin(R0 resection)
bull TEMS for localised leision in rectum
APR
bull When anal sphinter is involved or R0 resection mandates sphinter excision APR indicated in stage Iamp II
bull No survival advantage for APR when compared to wide local excision
STUDIES
bull Droesh et al -2005
bull 301 pt
bull 172-APR129- WLE
bull Mean survival same for both
bull A comparison of wide local excision with abdominoperineal resection in anorectal melanoma
bull Yap LB1 Neary P
bull Seventeen large case series from over the past 10 years were reviewed
bull Comparison of the survival of patients who underwent APR with those who underwent WLE showed no statistically significant advantage for either procedure in patients at all disease stages
bull APR should therefore only be performed when local excision is not possible or for palliative purposes
Role of lymph node dissection
bull Lymph node dissection ndash inguinalmesorectal-does not confer survival advantage although it improves locoregional control
bull Bollo et al(23 patients )
bull Moozar et al (14 patients )
bull Brady et al(retrospective analysis )
STAGE III
bull Systemic chemotherapy
bull Drugs used are akin to cutaneous melanoma
bull Commonly used drugs
Dacarbazine
Temozolamide
TARGETED THERAPY
bull cKIT BRAF mutation seen in some subgroup
bull Targeted therapy ndashcKIT ( Imatinib) BRAF (Verufunamib) in adjuvant and metastatic setting shows good response in phase II trial
bull Yeh et al Interim analysis shows median survival improves by 3-5 months
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
SPREAD
bull Lymphatic Spread Inguinal amp mesorectalnodes
bull Systemic LungLiverBrain Bone
DIAGNOSIS
bull Diagnosis can be made with visual inspection and anoscopy
bull commonly present as polypoidal mass
bull Distance from anal verge and mobility assessed
bull Clinically evident pigmented leision only in 20 of casesIn others pigmentation is obscured
bull 20 are amelanotic histologically
THROMBOSED PILE LIKE MASSS
Polypoidal lesion in colonoscopy
DIFFERENTIAL DIAGNOSIS
Anal carcinomalymphoma
Perianal haematoma
Thrombosed haemorrhoids
Anal or Rectal Polyp
INVESTIGATIONS
bull PROCTOSCOPY amp BIOPSY
bull USG ABDOMENPELVIS
bull ENDOLUMINAL USG
bull PET
USG abdomenpelvis to ro liver mets
ENDOLUMINAL USG Depth of invasion and nodal status
ROLE OF PET CT
bull Positron emission tomography (PET) may be helpful for staging of anorectal melanoma
bull The sensitivity was 74 to 100 and specificity 67 to 100
IMMUNOHISTOCHEMISTRY
Melanoma panel of markersS-100 proteinVimentinMelan-A
HMB-45To Ro other diseaseCytokeratins (Pagetrsquos disease) CD45 (lymphoma)
chromogranin and synaptophysin (undifferen-tiated carcinoma) CD34 (GIST) and Desmin and caldesmon (sarcoma)
STAGING
bull The staging of anal melanoma differs from that of cutaneous melanoma( based on Breslowclassification)
bull Anal melanoma is staged on a clinical basis focusing on locoregional and distant spread
( Clinics of Colorectal surgery vol19 Ross etal )
bull Stage I is local disease
bull stage II is local disease with regional lymph nodes
bull stage III is distant metastatic disease
STAGE I amp II
bull Surgical excision is the treatment of choice
bull Melanoma is highly resistant to RT Chemo No role either as defnitive treatment or as adjuvant therapy
SURGERY
bull WIDE LOCAL EXCISION ABDOMINO PERINEAL RESECTION for Stage III disease
bull Wide local excision (R0 resection ) is preferred
WIDE LOCAL EXCISION
bull Loan star retractor preferred
bull 1 cm margin(R0 resection)
bull TEMS for localised leision in rectum
APR
bull When anal sphinter is involved or R0 resection mandates sphinter excision APR indicated in stage Iamp II
bull No survival advantage for APR when compared to wide local excision
STUDIES
bull Droesh et al -2005
bull 301 pt
bull 172-APR129- WLE
bull Mean survival same for both
bull A comparison of wide local excision with abdominoperineal resection in anorectal melanoma
bull Yap LB1 Neary P
bull Seventeen large case series from over the past 10 years were reviewed
bull Comparison of the survival of patients who underwent APR with those who underwent WLE showed no statistically significant advantage for either procedure in patients at all disease stages
bull APR should therefore only be performed when local excision is not possible or for palliative purposes
Role of lymph node dissection
bull Lymph node dissection ndash inguinalmesorectal-does not confer survival advantage although it improves locoregional control
bull Bollo et al(23 patients )
bull Moozar et al (14 patients )
bull Brady et al(retrospective analysis )
STAGE III
bull Systemic chemotherapy
bull Drugs used are akin to cutaneous melanoma
bull Commonly used drugs
Dacarbazine
Temozolamide
TARGETED THERAPY
bull cKIT BRAF mutation seen in some subgroup
bull Targeted therapy ndashcKIT ( Imatinib) BRAF (Verufunamib) in adjuvant and metastatic setting shows good response in phase II trial
bull Yeh et al Interim analysis shows median survival improves by 3-5 months
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
DIAGNOSIS
bull Diagnosis can be made with visual inspection and anoscopy
bull commonly present as polypoidal mass
bull Distance from anal verge and mobility assessed
bull Clinically evident pigmented leision only in 20 of casesIn others pigmentation is obscured
bull 20 are amelanotic histologically
THROMBOSED PILE LIKE MASSS
Polypoidal lesion in colonoscopy
DIFFERENTIAL DIAGNOSIS
Anal carcinomalymphoma
Perianal haematoma
Thrombosed haemorrhoids
Anal or Rectal Polyp
INVESTIGATIONS
bull PROCTOSCOPY amp BIOPSY
bull USG ABDOMENPELVIS
bull ENDOLUMINAL USG
bull PET
USG abdomenpelvis to ro liver mets
ENDOLUMINAL USG Depth of invasion and nodal status
ROLE OF PET CT
bull Positron emission tomography (PET) may be helpful for staging of anorectal melanoma
bull The sensitivity was 74 to 100 and specificity 67 to 100
IMMUNOHISTOCHEMISTRY
Melanoma panel of markersS-100 proteinVimentinMelan-A
HMB-45To Ro other diseaseCytokeratins (Pagetrsquos disease) CD45 (lymphoma)
chromogranin and synaptophysin (undifferen-tiated carcinoma) CD34 (GIST) and Desmin and caldesmon (sarcoma)
STAGING
bull The staging of anal melanoma differs from that of cutaneous melanoma( based on Breslowclassification)
bull Anal melanoma is staged on a clinical basis focusing on locoregional and distant spread
( Clinics of Colorectal surgery vol19 Ross etal )
bull Stage I is local disease
bull stage II is local disease with regional lymph nodes
bull stage III is distant metastatic disease
STAGE I amp II
bull Surgical excision is the treatment of choice
bull Melanoma is highly resistant to RT Chemo No role either as defnitive treatment or as adjuvant therapy
SURGERY
bull WIDE LOCAL EXCISION ABDOMINO PERINEAL RESECTION for Stage III disease
bull Wide local excision (R0 resection ) is preferred
WIDE LOCAL EXCISION
bull Loan star retractor preferred
bull 1 cm margin(R0 resection)
bull TEMS for localised leision in rectum
APR
bull When anal sphinter is involved or R0 resection mandates sphinter excision APR indicated in stage Iamp II
bull No survival advantage for APR when compared to wide local excision
STUDIES
bull Droesh et al -2005
bull 301 pt
bull 172-APR129- WLE
bull Mean survival same for both
bull A comparison of wide local excision with abdominoperineal resection in anorectal melanoma
bull Yap LB1 Neary P
bull Seventeen large case series from over the past 10 years were reviewed
bull Comparison of the survival of patients who underwent APR with those who underwent WLE showed no statistically significant advantage for either procedure in patients at all disease stages
bull APR should therefore only be performed when local excision is not possible or for palliative purposes
Role of lymph node dissection
bull Lymph node dissection ndash inguinalmesorectal-does not confer survival advantage although it improves locoregional control
bull Bollo et al(23 patients )
bull Moozar et al (14 patients )
bull Brady et al(retrospective analysis )
STAGE III
bull Systemic chemotherapy
bull Drugs used are akin to cutaneous melanoma
bull Commonly used drugs
Dacarbazine
Temozolamide
TARGETED THERAPY
bull cKIT BRAF mutation seen in some subgroup
bull Targeted therapy ndashcKIT ( Imatinib) BRAF (Verufunamib) in adjuvant and metastatic setting shows good response in phase II trial
bull Yeh et al Interim analysis shows median survival improves by 3-5 months
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
bull Clinically evident pigmented leision only in 20 of casesIn others pigmentation is obscured
bull 20 are amelanotic histologically
THROMBOSED PILE LIKE MASSS
Polypoidal lesion in colonoscopy
DIFFERENTIAL DIAGNOSIS
Anal carcinomalymphoma
Perianal haematoma
Thrombosed haemorrhoids
Anal or Rectal Polyp
INVESTIGATIONS
bull PROCTOSCOPY amp BIOPSY
bull USG ABDOMENPELVIS
bull ENDOLUMINAL USG
bull PET
USG abdomenpelvis to ro liver mets
ENDOLUMINAL USG Depth of invasion and nodal status
ROLE OF PET CT
bull Positron emission tomography (PET) may be helpful for staging of anorectal melanoma
bull The sensitivity was 74 to 100 and specificity 67 to 100
IMMUNOHISTOCHEMISTRY
Melanoma panel of markersS-100 proteinVimentinMelan-A
HMB-45To Ro other diseaseCytokeratins (Pagetrsquos disease) CD45 (lymphoma)
chromogranin and synaptophysin (undifferen-tiated carcinoma) CD34 (GIST) and Desmin and caldesmon (sarcoma)
STAGING
bull The staging of anal melanoma differs from that of cutaneous melanoma( based on Breslowclassification)
bull Anal melanoma is staged on a clinical basis focusing on locoregional and distant spread
( Clinics of Colorectal surgery vol19 Ross etal )
bull Stage I is local disease
bull stage II is local disease with regional lymph nodes
bull stage III is distant metastatic disease
STAGE I amp II
bull Surgical excision is the treatment of choice
bull Melanoma is highly resistant to RT Chemo No role either as defnitive treatment or as adjuvant therapy
SURGERY
bull WIDE LOCAL EXCISION ABDOMINO PERINEAL RESECTION for Stage III disease
bull Wide local excision (R0 resection ) is preferred
WIDE LOCAL EXCISION
bull Loan star retractor preferred
bull 1 cm margin(R0 resection)
bull TEMS for localised leision in rectum
APR
bull When anal sphinter is involved or R0 resection mandates sphinter excision APR indicated in stage Iamp II
bull No survival advantage for APR when compared to wide local excision
STUDIES
bull Droesh et al -2005
bull 301 pt
bull 172-APR129- WLE
bull Mean survival same for both
bull A comparison of wide local excision with abdominoperineal resection in anorectal melanoma
bull Yap LB1 Neary P
bull Seventeen large case series from over the past 10 years were reviewed
bull Comparison of the survival of patients who underwent APR with those who underwent WLE showed no statistically significant advantage for either procedure in patients at all disease stages
bull APR should therefore only be performed when local excision is not possible or for palliative purposes
Role of lymph node dissection
bull Lymph node dissection ndash inguinalmesorectal-does not confer survival advantage although it improves locoregional control
bull Bollo et al(23 patients )
bull Moozar et al (14 patients )
bull Brady et al(retrospective analysis )
STAGE III
bull Systemic chemotherapy
bull Drugs used are akin to cutaneous melanoma
bull Commonly used drugs
Dacarbazine
Temozolamide
TARGETED THERAPY
bull cKIT BRAF mutation seen in some subgroup
bull Targeted therapy ndashcKIT ( Imatinib) BRAF (Verufunamib) in adjuvant and metastatic setting shows good response in phase II trial
bull Yeh et al Interim analysis shows median survival improves by 3-5 months
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
THROMBOSED PILE LIKE MASSS
Polypoidal lesion in colonoscopy
DIFFERENTIAL DIAGNOSIS
Anal carcinomalymphoma
Perianal haematoma
Thrombosed haemorrhoids
Anal or Rectal Polyp
INVESTIGATIONS
bull PROCTOSCOPY amp BIOPSY
bull USG ABDOMENPELVIS
bull ENDOLUMINAL USG
bull PET
USG abdomenpelvis to ro liver mets
ENDOLUMINAL USG Depth of invasion and nodal status
ROLE OF PET CT
bull Positron emission tomography (PET) may be helpful for staging of anorectal melanoma
bull The sensitivity was 74 to 100 and specificity 67 to 100
IMMUNOHISTOCHEMISTRY
Melanoma panel of markersS-100 proteinVimentinMelan-A
HMB-45To Ro other diseaseCytokeratins (Pagetrsquos disease) CD45 (lymphoma)
chromogranin and synaptophysin (undifferen-tiated carcinoma) CD34 (GIST) and Desmin and caldesmon (sarcoma)
STAGING
bull The staging of anal melanoma differs from that of cutaneous melanoma( based on Breslowclassification)
bull Anal melanoma is staged on a clinical basis focusing on locoregional and distant spread
( Clinics of Colorectal surgery vol19 Ross etal )
bull Stage I is local disease
bull stage II is local disease with regional lymph nodes
bull stage III is distant metastatic disease
STAGE I amp II
bull Surgical excision is the treatment of choice
bull Melanoma is highly resistant to RT Chemo No role either as defnitive treatment or as adjuvant therapy
SURGERY
bull WIDE LOCAL EXCISION ABDOMINO PERINEAL RESECTION for Stage III disease
bull Wide local excision (R0 resection ) is preferred
WIDE LOCAL EXCISION
bull Loan star retractor preferred
bull 1 cm margin(R0 resection)
bull TEMS for localised leision in rectum
APR
bull When anal sphinter is involved or R0 resection mandates sphinter excision APR indicated in stage Iamp II
bull No survival advantage for APR when compared to wide local excision
STUDIES
bull Droesh et al -2005
bull 301 pt
bull 172-APR129- WLE
bull Mean survival same for both
bull A comparison of wide local excision with abdominoperineal resection in anorectal melanoma
bull Yap LB1 Neary P
bull Seventeen large case series from over the past 10 years were reviewed
bull Comparison of the survival of patients who underwent APR with those who underwent WLE showed no statistically significant advantage for either procedure in patients at all disease stages
bull APR should therefore only be performed when local excision is not possible or for palliative purposes
Role of lymph node dissection
bull Lymph node dissection ndash inguinalmesorectal-does not confer survival advantage although it improves locoregional control
bull Bollo et al(23 patients )
bull Moozar et al (14 patients )
bull Brady et al(retrospective analysis )
STAGE III
bull Systemic chemotherapy
bull Drugs used are akin to cutaneous melanoma
bull Commonly used drugs
Dacarbazine
Temozolamide
TARGETED THERAPY
bull cKIT BRAF mutation seen in some subgroup
bull Targeted therapy ndashcKIT ( Imatinib) BRAF (Verufunamib) in adjuvant and metastatic setting shows good response in phase II trial
bull Yeh et al Interim analysis shows median survival improves by 3-5 months
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
Polypoidal lesion in colonoscopy
DIFFERENTIAL DIAGNOSIS
Anal carcinomalymphoma
Perianal haematoma
Thrombosed haemorrhoids
Anal or Rectal Polyp
INVESTIGATIONS
bull PROCTOSCOPY amp BIOPSY
bull USG ABDOMENPELVIS
bull ENDOLUMINAL USG
bull PET
USG abdomenpelvis to ro liver mets
ENDOLUMINAL USG Depth of invasion and nodal status
ROLE OF PET CT
bull Positron emission tomography (PET) may be helpful for staging of anorectal melanoma
bull The sensitivity was 74 to 100 and specificity 67 to 100
IMMUNOHISTOCHEMISTRY
Melanoma panel of markersS-100 proteinVimentinMelan-A
HMB-45To Ro other diseaseCytokeratins (Pagetrsquos disease) CD45 (lymphoma)
chromogranin and synaptophysin (undifferen-tiated carcinoma) CD34 (GIST) and Desmin and caldesmon (sarcoma)
STAGING
bull The staging of anal melanoma differs from that of cutaneous melanoma( based on Breslowclassification)
bull Anal melanoma is staged on a clinical basis focusing on locoregional and distant spread
( Clinics of Colorectal surgery vol19 Ross etal )
bull Stage I is local disease
bull stage II is local disease with regional lymph nodes
bull stage III is distant metastatic disease
STAGE I amp II
bull Surgical excision is the treatment of choice
bull Melanoma is highly resistant to RT Chemo No role either as defnitive treatment or as adjuvant therapy
SURGERY
bull WIDE LOCAL EXCISION ABDOMINO PERINEAL RESECTION for Stage III disease
bull Wide local excision (R0 resection ) is preferred
WIDE LOCAL EXCISION
bull Loan star retractor preferred
bull 1 cm margin(R0 resection)
bull TEMS for localised leision in rectum
APR
bull When anal sphinter is involved or R0 resection mandates sphinter excision APR indicated in stage Iamp II
bull No survival advantage for APR when compared to wide local excision
STUDIES
bull Droesh et al -2005
bull 301 pt
bull 172-APR129- WLE
bull Mean survival same for both
bull A comparison of wide local excision with abdominoperineal resection in anorectal melanoma
bull Yap LB1 Neary P
bull Seventeen large case series from over the past 10 years were reviewed
bull Comparison of the survival of patients who underwent APR with those who underwent WLE showed no statistically significant advantage for either procedure in patients at all disease stages
bull APR should therefore only be performed when local excision is not possible or for palliative purposes
Role of lymph node dissection
bull Lymph node dissection ndash inguinalmesorectal-does not confer survival advantage although it improves locoregional control
bull Bollo et al(23 patients )
bull Moozar et al (14 patients )
bull Brady et al(retrospective analysis )
STAGE III
bull Systemic chemotherapy
bull Drugs used are akin to cutaneous melanoma
bull Commonly used drugs
Dacarbazine
Temozolamide
TARGETED THERAPY
bull cKIT BRAF mutation seen in some subgroup
bull Targeted therapy ndashcKIT ( Imatinib) BRAF (Verufunamib) in adjuvant and metastatic setting shows good response in phase II trial
bull Yeh et al Interim analysis shows median survival improves by 3-5 months
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
DIFFERENTIAL DIAGNOSIS
Anal carcinomalymphoma
Perianal haematoma
Thrombosed haemorrhoids
Anal or Rectal Polyp
INVESTIGATIONS
bull PROCTOSCOPY amp BIOPSY
bull USG ABDOMENPELVIS
bull ENDOLUMINAL USG
bull PET
USG abdomenpelvis to ro liver mets
ENDOLUMINAL USG Depth of invasion and nodal status
ROLE OF PET CT
bull Positron emission tomography (PET) may be helpful for staging of anorectal melanoma
bull The sensitivity was 74 to 100 and specificity 67 to 100
IMMUNOHISTOCHEMISTRY
Melanoma panel of markersS-100 proteinVimentinMelan-A
HMB-45To Ro other diseaseCytokeratins (Pagetrsquos disease) CD45 (lymphoma)
chromogranin and synaptophysin (undifferen-tiated carcinoma) CD34 (GIST) and Desmin and caldesmon (sarcoma)
STAGING
bull The staging of anal melanoma differs from that of cutaneous melanoma( based on Breslowclassification)
bull Anal melanoma is staged on a clinical basis focusing on locoregional and distant spread
( Clinics of Colorectal surgery vol19 Ross etal )
bull Stage I is local disease
bull stage II is local disease with regional lymph nodes
bull stage III is distant metastatic disease
STAGE I amp II
bull Surgical excision is the treatment of choice
bull Melanoma is highly resistant to RT Chemo No role either as defnitive treatment or as adjuvant therapy
SURGERY
bull WIDE LOCAL EXCISION ABDOMINO PERINEAL RESECTION for Stage III disease
bull Wide local excision (R0 resection ) is preferred
WIDE LOCAL EXCISION
bull Loan star retractor preferred
bull 1 cm margin(R0 resection)
bull TEMS for localised leision in rectum
APR
bull When anal sphinter is involved or R0 resection mandates sphinter excision APR indicated in stage Iamp II
bull No survival advantage for APR when compared to wide local excision
STUDIES
bull Droesh et al -2005
bull 301 pt
bull 172-APR129- WLE
bull Mean survival same for both
bull A comparison of wide local excision with abdominoperineal resection in anorectal melanoma
bull Yap LB1 Neary P
bull Seventeen large case series from over the past 10 years were reviewed
bull Comparison of the survival of patients who underwent APR with those who underwent WLE showed no statistically significant advantage for either procedure in patients at all disease stages
bull APR should therefore only be performed when local excision is not possible or for palliative purposes
Role of lymph node dissection
bull Lymph node dissection ndash inguinalmesorectal-does not confer survival advantage although it improves locoregional control
bull Bollo et al(23 patients )
bull Moozar et al (14 patients )
bull Brady et al(retrospective analysis )
STAGE III
bull Systemic chemotherapy
bull Drugs used are akin to cutaneous melanoma
bull Commonly used drugs
Dacarbazine
Temozolamide
TARGETED THERAPY
bull cKIT BRAF mutation seen in some subgroup
bull Targeted therapy ndashcKIT ( Imatinib) BRAF (Verufunamib) in adjuvant and metastatic setting shows good response in phase II trial
bull Yeh et al Interim analysis shows median survival improves by 3-5 months
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
INVESTIGATIONS
bull PROCTOSCOPY amp BIOPSY
bull USG ABDOMENPELVIS
bull ENDOLUMINAL USG
bull PET
USG abdomenpelvis to ro liver mets
ENDOLUMINAL USG Depth of invasion and nodal status
ROLE OF PET CT
bull Positron emission tomography (PET) may be helpful for staging of anorectal melanoma
bull The sensitivity was 74 to 100 and specificity 67 to 100
IMMUNOHISTOCHEMISTRY
Melanoma panel of markersS-100 proteinVimentinMelan-A
HMB-45To Ro other diseaseCytokeratins (Pagetrsquos disease) CD45 (lymphoma)
chromogranin and synaptophysin (undifferen-tiated carcinoma) CD34 (GIST) and Desmin and caldesmon (sarcoma)
STAGING
bull The staging of anal melanoma differs from that of cutaneous melanoma( based on Breslowclassification)
bull Anal melanoma is staged on a clinical basis focusing on locoregional and distant spread
( Clinics of Colorectal surgery vol19 Ross etal )
bull Stage I is local disease
bull stage II is local disease with regional lymph nodes
bull stage III is distant metastatic disease
STAGE I amp II
bull Surgical excision is the treatment of choice
bull Melanoma is highly resistant to RT Chemo No role either as defnitive treatment or as adjuvant therapy
SURGERY
bull WIDE LOCAL EXCISION ABDOMINO PERINEAL RESECTION for Stage III disease
bull Wide local excision (R0 resection ) is preferred
WIDE LOCAL EXCISION
bull Loan star retractor preferred
bull 1 cm margin(R0 resection)
bull TEMS for localised leision in rectum
APR
bull When anal sphinter is involved or R0 resection mandates sphinter excision APR indicated in stage Iamp II
bull No survival advantage for APR when compared to wide local excision
STUDIES
bull Droesh et al -2005
bull 301 pt
bull 172-APR129- WLE
bull Mean survival same for both
bull A comparison of wide local excision with abdominoperineal resection in anorectal melanoma
bull Yap LB1 Neary P
bull Seventeen large case series from over the past 10 years were reviewed
bull Comparison of the survival of patients who underwent APR with those who underwent WLE showed no statistically significant advantage for either procedure in patients at all disease stages
bull APR should therefore only be performed when local excision is not possible or for palliative purposes
Role of lymph node dissection
bull Lymph node dissection ndash inguinalmesorectal-does not confer survival advantage although it improves locoregional control
bull Bollo et al(23 patients )
bull Moozar et al (14 patients )
bull Brady et al(retrospective analysis )
STAGE III
bull Systemic chemotherapy
bull Drugs used are akin to cutaneous melanoma
bull Commonly used drugs
Dacarbazine
Temozolamide
TARGETED THERAPY
bull cKIT BRAF mutation seen in some subgroup
bull Targeted therapy ndashcKIT ( Imatinib) BRAF (Verufunamib) in adjuvant and metastatic setting shows good response in phase II trial
bull Yeh et al Interim analysis shows median survival improves by 3-5 months
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
USG abdomenpelvis to ro liver mets
ENDOLUMINAL USG Depth of invasion and nodal status
ROLE OF PET CT
bull Positron emission tomography (PET) may be helpful for staging of anorectal melanoma
bull The sensitivity was 74 to 100 and specificity 67 to 100
IMMUNOHISTOCHEMISTRY
Melanoma panel of markersS-100 proteinVimentinMelan-A
HMB-45To Ro other diseaseCytokeratins (Pagetrsquos disease) CD45 (lymphoma)
chromogranin and synaptophysin (undifferen-tiated carcinoma) CD34 (GIST) and Desmin and caldesmon (sarcoma)
STAGING
bull The staging of anal melanoma differs from that of cutaneous melanoma( based on Breslowclassification)
bull Anal melanoma is staged on a clinical basis focusing on locoregional and distant spread
( Clinics of Colorectal surgery vol19 Ross etal )
bull Stage I is local disease
bull stage II is local disease with regional lymph nodes
bull stage III is distant metastatic disease
STAGE I amp II
bull Surgical excision is the treatment of choice
bull Melanoma is highly resistant to RT Chemo No role either as defnitive treatment or as adjuvant therapy
SURGERY
bull WIDE LOCAL EXCISION ABDOMINO PERINEAL RESECTION for Stage III disease
bull Wide local excision (R0 resection ) is preferred
WIDE LOCAL EXCISION
bull Loan star retractor preferred
bull 1 cm margin(R0 resection)
bull TEMS for localised leision in rectum
APR
bull When anal sphinter is involved or R0 resection mandates sphinter excision APR indicated in stage Iamp II
bull No survival advantage for APR when compared to wide local excision
STUDIES
bull Droesh et al -2005
bull 301 pt
bull 172-APR129- WLE
bull Mean survival same for both
bull A comparison of wide local excision with abdominoperineal resection in anorectal melanoma
bull Yap LB1 Neary P
bull Seventeen large case series from over the past 10 years were reviewed
bull Comparison of the survival of patients who underwent APR with those who underwent WLE showed no statistically significant advantage for either procedure in patients at all disease stages
bull APR should therefore only be performed when local excision is not possible or for palliative purposes
Role of lymph node dissection
bull Lymph node dissection ndash inguinalmesorectal-does not confer survival advantage although it improves locoregional control
bull Bollo et al(23 patients )
bull Moozar et al (14 patients )
bull Brady et al(retrospective analysis )
STAGE III
bull Systemic chemotherapy
bull Drugs used are akin to cutaneous melanoma
bull Commonly used drugs
Dacarbazine
Temozolamide
TARGETED THERAPY
bull cKIT BRAF mutation seen in some subgroup
bull Targeted therapy ndashcKIT ( Imatinib) BRAF (Verufunamib) in adjuvant and metastatic setting shows good response in phase II trial
bull Yeh et al Interim analysis shows median survival improves by 3-5 months
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
ROLE OF PET CT
bull Positron emission tomography (PET) may be helpful for staging of anorectal melanoma
bull The sensitivity was 74 to 100 and specificity 67 to 100
IMMUNOHISTOCHEMISTRY
Melanoma panel of markersS-100 proteinVimentinMelan-A
HMB-45To Ro other diseaseCytokeratins (Pagetrsquos disease) CD45 (lymphoma)
chromogranin and synaptophysin (undifferen-tiated carcinoma) CD34 (GIST) and Desmin and caldesmon (sarcoma)
STAGING
bull The staging of anal melanoma differs from that of cutaneous melanoma( based on Breslowclassification)
bull Anal melanoma is staged on a clinical basis focusing on locoregional and distant spread
( Clinics of Colorectal surgery vol19 Ross etal )
bull Stage I is local disease
bull stage II is local disease with regional lymph nodes
bull stage III is distant metastatic disease
STAGE I amp II
bull Surgical excision is the treatment of choice
bull Melanoma is highly resistant to RT Chemo No role either as defnitive treatment or as adjuvant therapy
SURGERY
bull WIDE LOCAL EXCISION ABDOMINO PERINEAL RESECTION for Stage III disease
bull Wide local excision (R0 resection ) is preferred
WIDE LOCAL EXCISION
bull Loan star retractor preferred
bull 1 cm margin(R0 resection)
bull TEMS for localised leision in rectum
APR
bull When anal sphinter is involved or R0 resection mandates sphinter excision APR indicated in stage Iamp II
bull No survival advantage for APR when compared to wide local excision
STUDIES
bull Droesh et al -2005
bull 301 pt
bull 172-APR129- WLE
bull Mean survival same for both
bull A comparison of wide local excision with abdominoperineal resection in anorectal melanoma
bull Yap LB1 Neary P
bull Seventeen large case series from over the past 10 years were reviewed
bull Comparison of the survival of patients who underwent APR with those who underwent WLE showed no statistically significant advantage for either procedure in patients at all disease stages
bull APR should therefore only be performed when local excision is not possible or for palliative purposes
Role of lymph node dissection
bull Lymph node dissection ndash inguinalmesorectal-does not confer survival advantage although it improves locoregional control
bull Bollo et al(23 patients )
bull Moozar et al (14 patients )
bull Brady et al(retrospective analysis )
STAGE III
bull Systemic chemotherapy
bull Drugs used are akin to cutaneous melanoma
bull Commonly used drugs
Dacarbazine
Temozolamide
TARGETED THERAPY
bull cKIT BRAF mutation seen in some subgroup
bull Targeted therapy ndashcKIT ( Imatinib) BRAF (Verufunamib) in adjuvant and metastatic setting shows good response in phase II trial
bull Yeh et al Interim analysis shows median survival improves by 3-5 months
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
IMMUNOHISTOCHEMISTRY
Melanoma panel of markersS-100 proteinVimentinMelan-A
HMB-45To Ro other diseaseCytokeratins (Pagetrsquos disease) CD45 (lymphoma)
chromogranin and synaptophysin (undifferen-tiated carcinoma) CD34 (GIST) and Desmin and caldesmon (sarcoma)
STAGING
bull The staging of anal melanoma differs from that of cutaneous melanoma( based on Breslowclassification)
bull Anal melanoma is staged on a clinical basis focusing on locoregional and distant spread
( Clinics of Colorectal surgery vol19 Ross etal )
bull Stage I is local disease
bull stage II is local disease with regional lymph nodes
bull stage III is distant metastatic disease
STAGE I amp II
bull Surgical excision is the treatment of choice
bull Melanoma is highly resistant to RT Chemo No role either as defnitive treatment or as adjuvant therapy
SURGERY
bull WIDE LOCAL EXCISION ABDOMINO PERINEAL RESECTION for Stage III disease
bull Wide local excision (R0 resection ) is preferred
WIDE LOCAL EXCISION
bull Loan star retractor preferred
bull 1 cm margin(R0 resection)
bull TEMS for localised leision in rectum
APR
bull When anal sphinter is involved or R0 resection mandates sphinter excision APR indicated in stage Iamp II
bull No survival advantage for APR when compared to wide local excision
STUDIES
bull Droesh et al -2005
bull 301 pt
bull 172-APR129- WLE
bull Mean survival same for both
bull A comparison of wide local excision with abdominoperineal resection in anorectal melanoma
bull Yap LB1 Neary P
bull Seventeen large case series from over the past 10 years were reviewed
bull Comparison of the survival of patients who underwent APR with those who underwent WLE showed no statistically significant advantage for either procedure in patients at all disease stages
bull APR should therefore only be performed when local excision is not possible or for palliative purposes
Role of lymph node dissection
bull Lymph node dissection ndash inguinalmesorectal-does not confer survival advantage although it improves locoregional control
bull Bollo et al(23 patients )
bull Moozar et al (14 patients )
bull Brady et al(retrospective analysis )
STAGE III
bull Systemic chemotherapy
bull Drugs used are akin to cutaneous melanoma
bull Commonly used drugs
Dacarbazine
Temozolamide
TARGETED THERAPY
bull cKIT BRAF mutation seen in some subgroup
bull Targeted therapy ndashcKIT ( Imatinib) BRAF (Verufunamib) in adjuvant and metastatic setting shows good response in phase II trial
bull Yeh et al Interim analysis shows median survival improves by 3-5 months
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
STAGING
bull The staging of anal melanoma differs from that of cutaneous melanoma( based on Breslowclassification)
bull Anal melanoma is staged on a clinical basis focusing on locoregional and distant spread
( Clinics of Colorectal surgery vol19 Ross etal )
bull Stage I is local disease
bull stage II is local disease with regional lymph nodes
bull stage III is distant metastatic disease
STAGE I amp II
bull Surgical excision is the treatment of choice
bull Melanoma is highly resistant to RT Chemo No role either as defnitive treatment or as adjuvant therapy
SURGERY
bull WIDE LOCAL EXCISION ABDOMINO PERINEAL RESECTION for Stage III disease
bull Wide local excision (R0 resection ) is preferred
WIDE LOCAL EXCISION
bull Loan star retractor preferred
bull 1 cm margin(R0 resection)
bull TEMS for localised leision in rectum
APR
bull When anal sphinter is involved or R0 resection mandates sphinter excision APR indicated in stage Iamp II
bull No survival advantage for APR when compared to wide local excision
STUDIES
bull Droesh et al -2005
bull 301 pt
bull 172-APR129- WLE
bull Mean survival same for both
bull A comparison of wide local excision with abdominoperineal resection in anorectal melanoma
bull Yap LB1 Neary P
bull Seventeen large case series from over the past 10 years were reviewed
bull Comparison of the survival of patients who underwent APR with those who underwent WLE showed no statistically significant advantage for either procedure in patients at all disease stages
bull APR should therefore only be performed when local excision is not possible or for palliative purposes
Role of lymph node dissection
bull Lymph node dissection ndash inguinalmesorectal-does not confer survival advantage although it improves locoregional control
bull Bollo et al(23 patients )
bull Moozar et al (14 patients )
bull Brady et al(retrospective analysis )
STAGE III
bull Systemic chemotherapy
bull Drugs used are akin to cutaneous melanoma
bull Commonly used drugs
Dacarbazine
Temozolamide
TARGETED THERAPY
bull cKIT BRAF mutation seen in some subgroup
bull Targeted therapy ndashcKIT ( Imatinib) BRAF (Verufunamib) in adjuvant and metastatic setting shows good response in phase II trial
bull Yeh et al Interim analysis shows median survival improves by 3-5 months
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
STAGE I amp II
bull Surgical excision is the treatment of choice
bull Melanoma is highly resistant to RT Chemo No role either as defnitive treatment or as adjuvant therapy
SURGERY
bull WIDE LOCAL EXCISION ABDOMINO PERINEAL RESECTION for Stage III disease
bull Wide local excision (R0 resection ) is preferred
WIDE LOCAL EXCISION
bull Loan star retractor preferred
bull 1 cm margin(R0 resection)
bull TEMS for localised leision in rectum
APR
bull When anal sphinter is involved or R0 resection mandates sphinter excision APR indicated in stage Iamp II
bull No survival advantage for APR when compared to wide local excision
STUDIES
bull Droesh et al -2005
bull 301 pt
bull 172-APR129- WLE
bull Mean survival same for both
bull A comparison of wide local excision with abdominoperineal resection in anorectal melanoma
bull Yap LB1 Neary P
bull Seventeen large case series from over the past 10 years were reviewed
bull Comparison of the survival of patients who underwent APR with those who underwent WLE showed no statistically significant advantage for either procedure in patients at all disease stages
bull APR should therefore only be performed when local excision is not possible or for palliative purposes
Role of lymph node dissection
bull Lymph node dissection ndash inguinalmesorectal-does not confer survival advantage although it improves locoregional control
bull Bollo et al(23 patients )
bull Moozar et al (14 patients )
bull Brady et al(retrospective analysis )
STAGE III
bull Systemic chemotherapy
bull Drugs used are akin to cutaneous melanoma
bull Commonly used drugs
Dacarbazine
Temozolamide
TARGETED THERAPY
bull cKIT BRAF mutation seen in some subgroup
bull Targeted therapy ndashcKIT ( Imatinib) BRAF (Verufunamib) in adjuvant and metastatic setting shows good response in phase II trial
bull Yeh et al Interim analysis shows median survival improves by 3-5 months
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
SURGERY
bull WIDE LOCAL EXCISION ABDOMINO PERINEAL RESECTION for Stage III disease
bull Wide local excision (R0 resection ) is preferred
WIDE LOCAL EXCISION
bull Loan star retractor preferred
bull 1 cm margin(R0 resection)
bull TEMS for localised leision in rectum
APR
bull When anal sphinter is involved or R0 resection mandates sphinter excision APR indicated in stage Iamp II
bull No survival advantage for APR when compared to wide local excision
STUDIES
bull Droesh et al -2005
bull 301 pt
bull 172-APR129- WLE
bull Mean survival same for both
bull A comparison of wide local excision with abdominoperineal resection in anorectal melanoma
bull Yap LB1 Neary P
bull Seventeen large case series from over the past 10 years were reviewed
bull Comparison of the survival of patients who underwent APR with those who underwent WLE showed no statistically significant advantage for either procedure in patients at all disease stages
bull APR should therefore only be performed when local excision is not possible or for palliative purposes
Role of lymph node dissection
bull Lymph node dissection ndash inguinalmesorectal-does not confer survival advantage although it improves locoregional control
bull Bollo et al(23 patients )
bull Moozar et al (14 patients )
bull Brady et al(retrospective analysis )
STAGE III
bull Systemic chemotherapy
bull Drugs used are akin to cutaneous melanoma
bull Commonly used drugs
Dacarbazine
Temozolamide
TARGETED THERAPY
bull cKIT BRAF mutation seen in some subgroup
bull Targeted therapy ndashcKIT ( Imatinib) BRAF (Verufunamib) in adjuvant and metastatic setting shows good response in phase II trial
bull Yeh et al Interim analysis shows median survival improves by 3-5 months
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
WIDE LOCAL EXCISION
bull Loan star retractor preferred
bull 1 cm margin(R0 resection)
bull TEMS for localised leision in rectum
APR
bull When anal sphinter is involved or R0 resection mandates sphinter excision APR indicated in stage Iamp II
bull No survival advantage for APR when compared to wide local excision
STUDIES
bull Droesh et al -2005
bull 301 pt
bull 172-APR129- WLE
bull Mean survival same for both
bull A comparison of wide local excision with abdominoperineal resection in anorectal melanoma
bull Yap LB1 Neary P
bull Seventeen large case series from over the past 10 years were reviewed
bull Comparison of the survival of patients who underwent APR with those who underwent WLE showed no statistically significant advantage for either procedure in patients at all disease stages
bull APR should therefore only be performed when local excision is not possible or for palliative purposes
Role of lymph node dissection
bull Lymph node dissection ndash inguinalmesorectal-does not confer survival advantage although it improves locoregional control
bull Bollo et al(23 patients )
bull Moozar et al (14 patients )
bull Brady et al(retrospective analysis )
STAGE III
bull Systemic chemotherapy
bull Drugs used are akin to cutaneous melanoma
bull Commonly used drugs
Dacarbazine
Temozolamide
TARGETED THERAPY
bull cKIT BRAF mutation seen in some subgroup
bull Targeted therapy ndashcKIT ( Imatinib) BRAF (Verufunamib) in adjuvant and metastatic setting shows good response in phase II trial
bull Yeh et al Interim analysis shows median survival improves by 3-5 months
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
APR
bull When anal sphinter is involved or R0 resection mandates sphinter excision APR indicated in stage Iamp II
bull No survival advantage for APR when compared to wide local excision
STUDIES
bull Droesh et al -2005
bull 301 pt
bull 172-APR129- WLE
bull Mean survival same for both
bull A comparison of wide local excision with abdominoperineal resection in anorectal melanoma
bull Yap LB1 Neary P
bull Seventeen large case series from over the past 10 years were reviewed
bull Comparison of the survival of patients who underwent APR with those who underwent WLE showed no statistically significant advantage for either procedure in patients at all disease stages
bull APR should therefore only be performed when local excision is not possible or for palliative purposes
Role of lymph node dissection
bull Lymph node dissection ndash inguinalmesorectal-does not confer survival advantage although it improves locoregional control
bull Bollo et al(23 patients )
bull Moozar et al (14 patients )
bull Brady et al(retrospective analysis )
STAGE III
bull Systemic chemotherapy
bull Drugs used are akin to cutaneous melanoma
bull Commonly used drugs
Dacarbazine
Temozolamide
TARGETED THERAPY
bull cKIT BRAF mutation seen in some subgroup
bull Targeted therapy ndashcKIT ( Imatinib) BRAF (Verufunamib) in adjuvant and metastatic setting shows good response in phase II trial
bull Yeh et al Interim analysis shows median survival improves by 3-5 months
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
STUDIES
bull Droesh et al -2005
bull 301 pt
bull 172-APR129- WLE
bull Mean survival same for both
bull A comparison of wide local excision with abdominoperineal resection in anorectal melanoma
bull Yap LB1 Neary P
bull Seventeen large case series from over the past 10 years were reviewed
bull Comparison of the survival of patients who underwent APR with those who underwent WLE showed no statistically significant advantage for either procedure in patients at all disease stages
bull APR should therefore only be performed when local excision is not possible or for palliative purposes
Role of lymph node dissection
bull Lymph node dissection ndash inguinalmesorectal-does not confer survival advantage although it improves locoregional control
bull Bollo et al(23 patients )
bull Moozar et al (14 patients )
bull Brady et al(retrospective analysis )
STAGE III
bull Systemic chemotherapy
bull Drugs used are akin to cutaneous melanoma
bull Commonly used drugs
Dacarbazine
Temozolamide
TARGETED THERAPY
bull cKIT BRAF mutation seen in some subgroup
bull Targeted therapy ndashcKIT ( Imatinib) BRAF (Verufunamib) in adjuvant and metastatic setting shows good response in phase II trial
bull Yeh et al Interim analysis shows median survival improves by 3-5 months
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
bull A comparison of wide local excision with abdominoperineal resection in anorectal melanoma
bull Yap LB1 Neary P
bull Seventeen large case series from over the past 10 years were reviewed
bull Comparison of the survival of patients who underwent APR with those who underwent WLE showed no statistically significant advantage for either procedure in patients at all disease stages
bull APR should therefore only be performed when local excision is not possible or for palliative purposes
Role of lymph node dissection
bull Lymph node dissection ndash inguinalmesorectal-does not confer survival advantage although it improves locoregional control
bull Bollo et al(23 patients )
bull Moozar et al (14 patients )
bull Brady et al(retrospective analysis )
STAGE III
bull Systemic chemotherapy
bull Drugs used are akin to cutaneous melanoma
bull Commonly used drugs
Dacarbazine
Temozolamide
TARGETED THERAPY
bull cKIT BRAF mutation seen in some subgroup
bull Targeted therapy ndashcKIT ( Imatinib) BRAF (Verufunamib) in adjuvant and metastatic setting shows good response in phase II trial
bull Yeh et al Interim analysis shows median survival improves by 3-5 months
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
Role of lymph node dissection
bull Lymph node dissection ndash inguinalmesorectal-does not confer survival advantage although it improves locoregional control
bull Bollo et al(23 patients )
bull Moozar et al (14 patients )
bull Brady et al(retrospective analysis )
STAGE III
bull Systemic chemotherapy
bull Drugs used are akin to cutaneous melanoma
bull Commonly used drugs
Dacarbazine
Temozolamide
TARGETED THERAPY
bull cKIT BRAF mutation seen in some subgroup
bull Targeted therapy ndashcKIT ( Imatinib) BRAF (Verufunamib) in adjuvant and metastatic setting shows good response in phase II trial
bull Yeh et al Interim analysis shows median survival improves by 3-5 months
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
STAGE III
bull Systemic chemotherapy
bull Drugs used are akin to cutaneous melanoma
bull Commonly used drugs
Dacarbazine
Temozolamide
TARGETED THERAPY
bull cKIT BRAF mutation seen in some subgroup
bull Targeted therapy ndashcKIT ( Imatinib) BRAF (Verufunamib) in adjuvant and metastatic setting shows good response in phase II trial
bull Yeh et al Interim analysis shows median survival improves by 3-5 months
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
TARGETED THERAPY
bull cKIT BRAF mutation seen in some subgroup
bull Targeted therapy ndashcKIT ( Imatinib) BRAF (Verufunamib) in adjuvant and metastatic setting shows good response in phase II trial
bull Yeh et al Interim analysis shows median survival improves by 3-5 months
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
PROGNOSTIC FACTORS
bull Tumour thickness
bull Ulceration
bull Mitotic rate
bull Nodal involvement
bull Relation to dentate line
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
PROGNOSIS
bull STAGE I ampII mean survival 11 ndash 20 months
bull STAGE III Less than 10 months
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
TAKE HOME MESSAGE
bull Anal melanoma is a rare and aggressive variant of mucosal melanoma
bull Often misdiagnosed as benign leision
bull High index of suspicion is needed
bull Immunohistochemistry is the gold standard for diagnosis
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
bull Surgery is the treatment of choice for stage Iamp II
bull Wide local excision is the preferred surgery
bull Role of targeted therapy is emerging
bull Mean survival is only 20 months
THANK U
THANK U