Melanoma

Question 1

Define a melanoma

Answer 1

A cancer arising from melanocytes in the epidermis

Question 2

What are the risk factors for Melanoma? [6]

Answer 2

• H/o skin cancer
• FMH
• Fair skin (Type 1 & 2 skin)
• Living in tropical country >1yr
• Working outdoors
• Immunosuppression

Question 3

How do you describe a lesion when suspecting malignancy? [5]

Answer 3

ABCDE. Check For:

• Asymmetry
• Variable border (irregular, hard to define)
• Variable Colour
• Uneven diameter
• Evolution (colour/size changes in moles)

Look with a dermatoscope

If you suspect, biopsy it

Question 4

What are the main morphological types of melanoma? [5]

Indicate which is the most common

Answer 4

*Superficial spreading
Lentigo Maligna melanoma
Nodular Melanoma 
Acral Lentiginous Melanoma
Ocular Melanoma

Question 5

Describe superficial spreading melanomas [5]

Answer 5

• Superficial spreading
• slowly enlarging
• pigmented lesion with
• colour variation and irregular border
• growth initially in radial plane with lesion remaining thin
• but may be followed by vertical invasion; usually on male trunks or female legs

Question 6

Lentigo Maligna melanoma [4]

Answer 6

• Slow growing melanomas
• usually appearing on face
• Older people who’ve had a lot of sun exposure over the years,
• Appears as stains on the skin

Question 7

Nodular melanoma [3]

Answer 7

• most aggressive
• no radial growth so lesions grow rapidly and invade deeply causing ulcerations
• usually dark and pigmented but can be amelanotic

Question 8

Acral Lentiginous Melanoma [4]

Answer 8

• unrelated to sun
• palms, soles and subungal areas (nails)
• more common in Black and Asian skin
• urgent referral for new pigmented line under nail, especially if extends to nail fold (Hutchinson’s nail sign)*

Question 9

Melanoma staging [4]

Answer 9

Stage I: T <2mm thick, N0, M0
Stage II: T>2mm thick, N0, M0
Stage III: N>1, M0
Stage IV: M>1

Question 10

Describe investigation and management in a suspected lesion [4]

Answer 10

Excision biopsy is both diagnostic and therapeutic for non-invasive stages
Sentinal lymph node biopsy

• Any unusual growing/changing pigmented lesion
• Excise with 2mm margin and cuff of subcutaneous fat
• Measurement of tumor depth ie Breslow thickness is important

Question 11

Next steps if lesion is confirmed to be malignant melanoma?

Answer 11

• If malignant melanoma confirmed, wide excision up to 3mm is required

Question 12

Management of metastatic cancer [1]

Treatment for stage 3

Answer 12

Metastatic melanoma is not responsive to radiotherapy

Stage 3 - adjuvant chemotherapy

Question 13

Long term management [2]

Answer 13

Regular follow up

2* prevention i.e. suncream, no tanning beds etc

Question 14

Treatment for stage IV [4]

Answer 14

Stage 4

• Chemotherapy
• IFN alpha, IL-2
• Vemurafenib - blocks B-Raf Protein (requires B-raf mutation in the cancer)
• Ipilimumab - inhibits CTLA-4 molecules

Question 15

Prognosis is dependent on… [2]

Answer 15

Excision completeness

Breslow thickness

Question 16

Common benign melanocytes naevi [3]

Answer 16

Congenital melanocytic naevi
Acquired melanocytes naevi
Halo naevi

Question 17

Congenital melanocytic naevi [3]

Answer 17

• Usually >1cm
• present at birth or in early neonatal period
• Increased risk of malignant transformation if >20cm

Question 18

Acquired melanocytes naevi [4]

Answer 18

• present in childhood or young adults
• starts as evenly pigmented junctional naevus before becoming a dome shaped compound naevus
• > losing its epithelial components (intradermal naevus)
• disappears in old age

Question 19

Halo naevi [3]

Answer 19

• white halo develops around a benign melanocytic naevi in adolescence
• due to loss of melanocytes by lymphocytes
• BUT in adults, may indicate melanoma elsewhere so check eyes, skin