Melanoma Flashcards by Bethany Edridge

How many registrations and deaths were there in NZ in 2013?

2400 reg

350 deaths

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Who has the highest rates of Melanoma in the world?

NZ and Aus

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How common is Melanoma? And how common is it to die from it?

4th most common cancer in NZ
4th most common cause of death - men
6th most common cause of death - women

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Is there a discrepancy between men and women/Maori and non Maori?

Men have higher incidence and mortality rates than women and it’s increasing.
More common in non-Maori

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Melanoma Epidemiology

NZ and Aus = highest rates in the world
4th most common cancer in NZ
4th most common cause of death - men
6th most common cause of death - women
2400 reg and 350 deaths
Men have higher incidence and mortality rates and it's increasing. 
More common in non-Maori

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Why is incidence so high in NZ?

Exposure to UV
- 40% higher in summer than corresponding latitudes in N hemisphere
- Many melanoma types linked to UV radiation
- Hole in the Ozone layer
Continuous exposure to sun - outdoor vocations and lifestyles
- Healthy tan attitude
High proportion of population with skin types that burn easily - Genetic disposition/heritage
- English, Irish, Scottish

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What risk factors are related to Genetic characteristics?

Genetic characteristics

Fair features
Large # of moles
Immunosuppression
Previous diagnosis or melanoma/skin cancers

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What are the risk factors associated with Melanoma?

Genetic characteristics
Strong family history
Excess sun exposure/burns during childhood/adolescence = greater risk
Increased risk with use of sunbeds under the age of 35
Carcinogens - petroleum, benzene and pesticides

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What are the 4 Predictive Factors for Melanoma?

Thickness: Breslow Scale + TNM
Ulceration: Ulcerated tumours typically have increased thickness compared with non-ulcerated and therefore have a tendency to metastasise
Mitotic rate: # of mitoses/mm^2, the greater the number of mitoses = worse prognosis
Lactate Dehydrogenase (LDH): Serum levels found in blood - most predictive of decreased survival

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What does the A stand for in Clinical Presentation and what does it mean?

A - Asymmetry - the shape of one half does not match the other

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What does the B stand for in Clinical Presentation and what does it mean?

B - Borders - the edges are ragged, uneven, blurred or irregular in outline, the pigment may spread into the surrounding skin

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What does the C stand for in Clinical Presentation and what does it mean?

C - Colour variation - colour is uneven, and may include colours like black, brown and tan

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What does the D stand for in Clinical Presentation and what does it mean?

D - Diameter - larger than 6mm or if the size changes and increases

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What does the E stand for in Clinical Presentation and what does it mean?

E - Evolving - getting larger or changing

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What is the surgical margin for melanoma in situ?

5-10mm

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What is the surgical margin for a lesion less than 1mm thick?

10mm

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What is the surgical margin for a lesion 1-2mm thick?

10-20mm

What is the surgical margin for a lesion 2-4mm thick?

10-20mm

What is the surgical margin for a lesion more than 4mm thick?

20mm

When is a SLNB recommended/indicated?

For lesions thicker than 1mm

What investigations are used for Melanoma?

Complete history and physical exam
Biopsies
FNA of LN
Routine blood tests
Ultrasound
CT
MRI
PET-CT

What does biopsy selection depend on?

Tumour site
Tumour size
Consideration of future tmt

What are the types of biopsies used for Melanoma?

Excisional biopsies (1-3mm thick) ideal and where appropriate
- Sent for pathological examination
Full thickness incisional biopsy if the lesion is too large to completely excise
Punch biopsy of the thickest part
SLNB

What does Melanoma NZ do?

Provides info, promotion of early checks, involvement, support, research and clinical trials
Works closely with SunSmart and Health Promotion agency
Melanoma Awareness Week - Go Spotty Day

What does MelNet (The Melanoma Network of NZ) do?

Network of professionals working to reduce the incidence and impact of Melanoma in NZ Promotes education and the advancement of best practice Holds 3 yearly summits

Where are normal melanocytes found and what do they do?

They are found in the basal layer of the epidermis | They produce a protein called melanin which protects the skin by absorbing UV radiation

What cell does Melanoma originate from and how does it begin?

Melanocyte cells. It starts from an uncontrolled proliferation of transformed melanocyte stem cells

What is Melanoma in Situ?

Melanoma cells confined to the epidermis

What is invasive melanoma?

When the melanoma cells have grown through the basement membrane and into the dermis

What is metastatic melanoma?

Spread of melanoma via lymphatics or blood stream to other organs (lung, brain, bone, liver and skin)

What is included in a Melanoma pathology report?

- Diagnosis of primary melanoma - Breslow thickness to the nearest 0.1mm - Clarke's Level of Invasion - Margins of excision - Mitotic rate - Whether or not there is ulceration - Comments about the cell type, growth pattern, invasion of blood vessels or nerves, inflammatory response, regression, and whether there is associated in-situ disease and or naevus (mole) - Immunochemical info (if tested)

What are the 5 subtypes of Melanoma?

``` Superficial Spreading Nodular Lentigo Maligna Acral Lentiginous Desmoplastic ```

What is the Breslow scale?

Max thickness of lesion from the top of the skin's surface to the deepest point of invasion Measured by a pathologist with a microscope Main measurement to decide the surgical margin, if SLNB or if further tmt is necessary Use this as well as TNM staging to determine tmt

What is Clarke's Level?

Indicates how many layers of the skin the melanoma had invaded Deeper level = greater risk of metastasis Less reliable and more subjective than Breslow - also less indicative of outcomes

When is RT used to treat Melanoma?

- As a definitive tmt for unresectable disease or if the primary tmt is limited (due to location) - As adjuvant tmt post lymphadenectomy to improve regional control - Metastatic or recurrent disease - Palliation to primary, metastatic or regional foci to prevent pain, ulceration or bleeding

What are the indications for adjuvant RT?

- Large lymph nodes (>3cm) - 2 or more + LN - Extranodal extension

What is the conventional fractionation schedule used?

48Gy in 20#, 2.4Gy/#

What is the hypofractionated schedule used?

30Gy in 5#, 6Gy/#, 2#/week. Often used for more radioresistant cells Improves local control rates

What is the palliative prescription used?

6Gy/# given 1# per week for 5-6 weeks | 30Gy/10#

When would stereotactic RT be used and what is the prescription?

Pts with good performance status with solitary brain mets | 15-24Gy depending on location

What types of RT are used?

``` 3DCRT most common, but IMRT and VMAT can be used. Superficial better suited to some subtypes (lentigo maligna melanoma) Brachy used (superflab bolus or custom cast) ```

What are the options for Metastatic Melanoma?

Surgery - try to remove the lesion to prevent pain and ulceration RT - Palliation to primary/to previously disected nodal basin Chemotherapy - Dacarbazine Immunotherapy Stereotactic RT - Brain mets

Melanoma Flashcards

RT + O Exam