Melanoma (575-595)

Question 1

Whar are the red flag features in a patient with a pigmented lesion that would appear to be suspicious or signify a malignant chang?;

Answer 1

ABCDEFGHI. Asymetry. Bleedin. Colour variation. Diameter (>6mm suspicious) Evolving/elevation. Further lesions (satellate lesions). Greater than 6mm. Halo (area of faint colour around lesion). Irregular border.

Question 2

Define melaoma. What are the types of melanocytic naevi?;

Answer 2

Melanoma is a neoplasm of epidermal melanocytes which arise from neural crest. Types- 1. Junctional nevus (flat, brown to black). 2. Compound nevus (slightly elevate). 3. Intradermal nevus (dome shaped).

Question 3

Name some risk factors for developing a melanoma;

Answer 3

UV exposure- sun beds, sun burn. Age- aged>50. Previous melanoma. Skin tone- Fitzpatrick type 1 (fair skin). Genetic- family history, predisposing conditions. Other- immunosuppresion (e.g. organ transplant).

Question 4

Name some conditions that predispose to the development of a melanoma;

Answer 4

Multipe dysplastic naevi syndrome (?50 naevi, 2mm or greater). Xeroderma pigmentosum. Giant congential melonocytic naevus. Albinism.

Question 5

What genes are associated with increased risk of melanoma?;

Answer 5

Mutations to proto-oncogens- BRAF and NRAS. Mutations to tumour suppressor genes- CDKN2A, XP gene.

Question 6

In which layer of skin does a melanoma arise?;

Answer 6

Basal layer of epidermis (neural crest).

Question 7

What is the embryological origin of melanocytes;

Answer 7

Neural creast.

Question 8

What are the main types of melanoma?;

Answer 8

Superficial spreading (60% - large, flat, irregularly pigmented), Nodular (30% - rapidly growing, bleedin, ulcerated). Lentigo maligna melanoma (large and flat). Acral lentiginous (palms soles or under nails.- Bob Marely)

Question 9

What is the most common type of melanoma?;

Answer 9

Superficial spreading (60%)

Question 10

Which types of melanoma have the best and worst (poorest) prognosis?;

Answer 10

Best- superficial spreading. Worst- acral

Question 11

What tumour markers are used in the diagnosis of melanoma?;

Answer 11

HMB 45, S100

Question 12

What would be your next course of action?;

Answer 12

Excision biopsy with 2mm margin under local. Send for histology.

Question 13

What might be the concerning features in the histopathology report?;

Answer 13

High mitotic index. Verticular growth pahse. Ulceration of tumour. Lymph node involvement. Perivascular or perilymphatic invasion.

Question 14

What is the difference between Breslow thickness and Clarke’e level?;

Answer 14

Breslow thickness- the vertical thickness of the tumour measured from granular layer to deepest point to 0.1mm (can predict prognosis). Clarke’s level- what layer of skin the tumour has invaded to,

Question 15

What are the prognositic indicators for a melanoma and what features have the worst prognosis?;

Answer 15

Poor prognosis- lymph node involvement, metastasis, high breslow thickness, head & neck melanoma, raised LDH

Question 16

What excision argins would you consider for a wide local ecision of a melanoma that has a Breslow depth of 1.8mm?; https://teachmesurgery.com/plastic-surgery/skin-cancer/melanoma/

Answer 16

1-2cm peripheral margins. ADD BRESLOW DEPTH TABLE

Question 17

How would you manage a 4.2mm Breslow thick melanoma in the arm of a 24 year old woman with positive sentinel lymph nodes but no evidence of systemic spread?;

Answer 17

Further imaging- CT scan to assess for metastasis and lymphoscintatography to identify nodes involved. Treatment- Wide local excision for melanoma (at least 3cm margins). Consider axillary node clearance radiotherapy for nodes +/- immunotherapy agents or chemotherapy agents.

Question 18

What are the treament options for managing patients with different stages of melanoma?; ADD AJCC STAGING TABLE https://teachmesurgery.com/plastic-surgery/skin-cancer/melanoma/

Answer 18

Conservative- melanoma will spread. Surgery- wide local excision (using AJCC staging) +/- lymph mnode clearance. Radiotherapy- for lymph nodes. Chemotherapy- can be used if mets. Immunotherapy- can be used if mets (ipimumab).

Question 19

What treatment options are available for treating metastatic skin depositis?;

Answer 19

Immunotherapy- ipilimumab (monoclonal antibody). Or chemotherapy.

Question 20

What is the five-year prognosis for a patient with a Stage 1 melanoma?;

Answer 20

Over 90%.

Question 21

How would you follow-up a patient with a melanoma?;

Answer 21

3 monthly basis for minimum 2 years for uncomplicated melanoma - if no concerns discharge after 2 years. If advanced/aggressive melanoma than follow up us lifelong (every 3 months)