4Melanoma Represents 4% of all cancers Most common malignancy in women agedIncidence is rising faster than any other cancerLifetime risk of developing melanoma now about 1 in 7030% arise in existing nevi
5Risk Factors Fair skin Presence of atypical nevi Personal history of melanomaFamily history of atypical nevi or melanomaHistory of blistering sunburnCongenital nevi (incidence increases with increasing size)
6ABCDs of Melanoma Recognition Asymmetry - one half of lesion does not look like the otherBorders - Scalloped border or focal extension into surrounding skinColor variegation - varying hues and colors (black, brown, red, blue and whiteDiameter - >6mm
7Superficial Spreading Melanoma Most common subtype accounting for 70-80% of melanomasF > M mostly CaucasiansMost often on trunk and extremitiesTend to be > 6mmSpread laterally for years before developing nodules
8Nodular Melanoma Account for 10-15% of melanomas M = F Most often found on the extremitiesEvolve over months and extend vertically with little lateral spread
9Lentigo Maligna and Lentigo Maligna Melanoma Account for 5-10% of melanomasArise most often on the face, neck or dorsal arms in older CaucasiansM = F. Develop over years or decadesLentigo Maligna represents in situ lesion and 5% progress to invasive LMM
10Amelanotic Melanoma Descriptive term for non- pigmented melanoma Any type can be amelanotic2% of all melanomas are amelanoticMalignant cells produce little or no pigmentPoorer prognosis due to delayed diagnosis
11Acral Lentiginous Melanoma Accounts for 7% of melanomasOccurs on hands, feet, nails and mucous membranesMost common melanoma in blacks and asians > 50%Least common in CaucasiansLeading cause of skin cancer deaths
12Acral Lentiginous Melanoma Most patients are betweenUsually slow growingOften difficult to detect early which leads to poor prognosisOften begins as a brown/black streak under a nail or bruise like area on acral skin
13Acral Lentiginous Melanoma Diagnosis is by clinical suspicion and tissue biopsyTreatment is surgical excision with appropriate margins and in some cases requires amputationAdditional studies(PET, CT, SNL) are performed if indicated
14WorkupAll suspicious lesions should be biopsied. This does not increase the risk of metastases.Excisional or punch biopsy allows for accurate measurement of Breslow’s depth. Never shave biopsy a suspected melanoma.Breslow’s depth, ulceration and mitotic rate are most important features histologicallySentinel lymph node biopsy should be done on all melanomas >=1mmFor patients with positive sentinel nodes, PET/CT scanning should be performed to rule out distant metastases
15TreatmentWide local excision with adequate margins is treatment of choiceAppropriate margin is determined by Breslow’s depthMelanoma in situ requires a margin of 0.5 cmMelanoma up to 2.0 mm requires a 1.0 cm margin with full thickness dermis and subcutaneous fatMelanoma > 2.0 mm requires a 2.0 cm margin with full thickness dermis and subcutaneous fat
16Sentinel Node BiopsyLymphoscintigraphy procedure where a sulfur colloid tagged with technetium-99m is injected at the site of the initial tumor and followed to the draining lymph node basin15 minutes prior to dissection blue dye is injected at the same site.The nodal basin is then dissected and inspected for those nodes that take up the dye and are shown by Geiger counter to have taken up the radioactive material. These are the sentinel node(s)
17Sentinel NodesOnce identified the sentinel nodes are removed and examined histologically for evidence of tumor spreadIf sentinel nodes are positive full elective lymph node dissection may be done as well as further staging workupIf sentinel node(s) is negative no further workup is required
21Adjuvant Therapy ELND has shown no real increase in survival Adjuvant therapy with interferon was often recommended for those with advance stages of disease but did not significantly increase survivalInterferon has numerous side effects (flu like symptoms) making it difficult to complete treatment
22Adjuvant TherapyZelboraf (vemurafenib) - For patients with metastatic melanoma with tumors that express a gene mutation called BRAF V600E.BRAF helps regulate cell growth. The variant of BRAF targeted by Zelboraf is a gene mutation that allows melanoma cancer cells to spreadAlmost 50 percent of all melanoma tumors have the BRAF genetic mutationNot yet clear how long Zelboraf can increase melanoma survival.
23Adjuvant TherapyYervoy (ipilimumab) - For the treatment of late-stage, metastatic melanomaPatients taking Yervoy survived an average of 10 months after starting treatmentA monoclonal antibody that blocks a crucial switch on immune cells called CTLA-4. Cancers use this switch to turn off the body's anticancer immune responses.Nearly 13% of patients taking Yervoy had severe or fatal autoimmune reactions.
24Melanoma SurvivalStage IA: The 5-year survival rate is around 97%. The 10- year survival is around 95%.Stage IB: The 5-year survival rate is around 92%. The 10- year survival is around 86%.Stage IIA: The 5-year survival rate is around 81%. The 10- year survival is around 67%.Stage IIB: The 5-year survival rate is around 70%. The 10- year survival is around 57%.Stage IIC: The 5-year survival rate is around 53%. The 10- year survival is around 40%.
25Melanoma SurvivalStage IIIA: The 5-year survival rate is around 78%. The 10-year survival is around 68%.Stage IIIB: The 5-year survival rate is around 59%. The 10-year survival is around 43%.Stage IIIC: The 5-year survival rate is around 40%. The 10-year survival is around 24%.Stage IV: The 5-year survival rate for stage IV melanoma is about 15% to 20%. The 10-year survival is about 10% to 15%.
26Prevention Wear protective clothing Always use sunscreen SPF Must block both UVA and UVBAvoid midday sun 10 am - 3 pmSelf skin examsAvoid sunburn
27Follow UpAll melanoma patients should have semi- annual skin examinations including lymph node assessment for 2-3 years followed by annual exams for their lifetimeAppropriate scanning should continue as indicatedAll first degree relatives should have a baseline skin exam and annual exams for life