Melanoma

Question 1

Melanoma: four subtypes in worsening order of prognosis

Answer 1

Lentigo Maligna
Superficial Spreading
Acral Lentiginous
Nodular

Question 2

Melanoma:
TNM staging system
What lab test may be relevant

Answer 2

T stages into T1=< 1 mm, T2 = 1-2 mm, T3 = 2-4 mm, T4 > 4mm. There is an a. and b. designation representing the absence/presence of ulceration or, in the case of T1 lesions only.

Lab test: LDH elevation

Question 3

Melanoma: what tests to get for early stage

Answer 3

Examine all lymph node basins. Get chest X-ray and liver panel.
Always include serum LDH in evaluation as this can be used to monitor for occult recurrence/metastases

Question 4

Melanoma: Who to offer SLNB

What test do you order preoperatively?

Answer 4

Breslow depth 1-4 mm.
.75mm with ulceration, regression, nodular pathology

Get preoperative radiolabeled lymphoscintigraphy to define drainage pattern of the primary (this is especially important in truncal melanomas, whose drainage patterns are not predictable); can then either intraoperatively localize sentinel node with isosulfan blue and/or handheld gamma counter

Question 5

Interferon alfa-2b

Answer 5

is offered as adjuvant therapy to patients with melanomas deeper than 4 mm and no distant metastatic disease or those with Stage III disease. Given high-dose intravenous for one month, then 11 months of three times weekly subcutaneous injection

Question 6

What is the treatment for anal melanoma?

Answer 6

Anal melanoma is almost uniformly fatal. No evidence that APR should be done except if lesion has invaded the sphincter muscle and patient has severe pain or is incontinent. Consider any treatment as palliative, so local excision is all that is usually needed. No role for SNB, interferon, node dissection, or chemo-immunotherapy outside of a research center

Question 7

What is the treatment for subungual melanoma?

Answer 7

Split or lift nail to biopsy these. If finger involved, can amputate distal phalanx only as long as interphalangeal area is not involved; for all toes, Ray amputation since it is better to weight-bear on the metacarpal than on phalanx.

Question 8

melanoma presenting as an involved node with an unknown primary

Answer 8

do extensive staging work-up to rule out disease elsewhere. If this is negative, treat the patient as Stage III patient – do therapeutic node dissection and offer protocol adjuvant therapy.