Melanoma,Edward Buckingham, M.D. Combined Plastics Conference September 6, 2000,Melanoma - Outline,General statistics and development Risk factors and patient assessement Pathology and prognosis Work-up and staging Surgical treatment Lymph node controversy/sentinel node Adjuvant therapy,Melanoma - Data,Incidence increase fastest Mortality increase 2nd only to lung 5th most prevalent, incidence 7%/year increase5% skin cancer, 75% skin cancer death 1/75 in 2000, 1/1500 in 1935 20% H&N, 51% facial, 26% scalp, 16% neck, 9% ear,Development of Nevi,Melanocytes dendritic, neural crest, basal cell layer synthesis of melanin 1/10 to keratinocytes hyperplasia- tanning/lentigines, increased ratio Nevus transformation poorly understood dendritic- rounded no longer lentigionous pattern- nests,Development of Nevi,Junctional nevi nests along dermal-epidermal junction Compound nevi “invade” dermis, first as nests then cords and single cells Dermal nevi junctional component lost,Evolution of Nevi,Melanocyte Hyperplasia,Junctional Nevi,Compound Nevi,Dermal Nevi,Developement of Melanoma,Questionable benign melanocytes progressive hyperplasia/dysplasia Radial growth in epidermis, lines of radii, no expansive nests or nodules slow unrestricted , no metastatic potential,Development of Melanoma,Vertical growth vertically into dermis expansive and coalescent nests and nodules metastatic potential dermal lymphatic and vascular invasion Growth patterns biphasic- slow radial months to years- rapid vertical growth monophasic- rapid vertical growth only,Evolution of Melanoma,Dysplastic Nevi,border melanocytic nevi and malignant melanoma clinical resembles malignant melanoma lentiginous compound nevus, prominent bridging across rete ridges aberrant in inter-rete spaces lamellar fibrosis of papillary dermis, variable lymphoid response,Dysplastic Nevi,Dysplastic Nevi,Types of Melanoma,Acral lentiginous Mucosal melanoma Superfical spreading melanoma Lentigo maligna melanoma Nodular melanoma,Superficial spreading,most common head and neck, 50% 4th to 5th decade clinical mixture of brown/tan, pink/white irregular borders, biphasic growth irregular nests in epidermis underlying lymphoid infiltrate enlarged nests and single cells in all epidermal layers,Superficial spreading,Lentigo maligna,20% of head and neck longest radial growth phase 15 yrs elderly sun exposed areas clinical dark, irregular ink spot contiguous lintiginous proliferation, dyshesive, variable shape, atrophic epidermis, infundibular basal cell layer of hair follicles,Lentigo maligna,Nodular melanoma,30% of head and neck 5th decade aggressive monophasic growth sun-exposed and nonexposed areas well circumscribed blue/black or nodular with involution in irregular plaque downward tumorigenic growth, expand papillary dermis into reticular dermis,Nodular melanoma,Mucosal melanoma,8% head and neck histologic staging little use local control predicts survival neck dissection for clinical N+ XRT for histo N+ adjuvant interferon alpha 2-b,Risk factors,Type I or II skin atypical and congenital nevi actinic skin changes history of melanoma family history of melanoma, atypical nevi history of significant sun exposure (blistering),Clinical,early, increase in size, change in shape or color of pigmented lesion most common symptom pruritis late, tenderness, bleeding, ulceration ABCDEs (asymmetry, border, color, diameter, elevation, surrounding tissue) Epiluminescence microscopy (ELM),Biopsy,excisional biopsy or saucerization if small incisional if large Depth of biopsy must be to sub-Q fat if melanoma a second excision must be performed,Pathology,diagnosis, tumor thickness in millimeters, margins histologic subtype, anatomic site, Clark level, mitotic rate, growth phase, ulceration, regression, lymphocytes, angiolymphatic spread, neurotropism, microsatellitosis, precursor lesion,Prognosis,Breslow (thickness in millimeters) strongest predictor,Prognosis,Clark level less predictive, thin skin useful,Prognosis,anatomic site, ulceration, gender, histologic type, nodal disease head and neck- scalp worse extremity better trunk women better men lymph node + Breslow thickness, ulceration, # pos. nodes Cohen 10 yr survival # nodes positive,Work-up,H&P entire skin, inguinal, axillary, supraclavicular, H&N nodes,especially primary drainage brain, bone, GI, constitutional symptoms palpable nodes FNA Labs and imaging vary, CXR to routine CT chest and LFT H&N CT neck routine If stage III(regional) or IV (distant) - CT head, chest, abdomen, pelvis,Work-up,FDG-PET some use in distant disease sensitivity 17% in study with SLN biopsy,Staging-Clark,Level I - in situ at basement membrane Level II - through basement membrane into papillary dermis Level III - spread to papillary/reticular interface Level IV - spread to reticular dermis Level V - sub-Q invasion,Staging-Breslow,4.00 mm - thick,Staging,CS/PS (I, II, III) AJCC- Stage I and II - local, III - regional IV - distant,AJCC Staging,