Melanoma, C64 P471-476 Flashcards by Tiggee R

What is it?

P471

Neoplastic disorder produced by
malignant transformation of the
melanocyte; melanocytes are derived
from neural crest cells

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Which patients are at
greatest risk?
P471

White patients with blonde/red hair, fair
skin, freckling, a history of blistering
sunburns, blue/green eyes, actinic
keratosis
Male > female

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What are the most common
sites (3)?
P471

Skin
Eyes
Anus
(Think: SEA = Skin, Eyes, Anus)

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What is the most common
site in African Americans?
P472

Palms of the hands, soles of the feet

acral lentiginous melanoma

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What characteristics are
suggestive of melanoma?
P472

Usually a pigmented lesion with an
    irregular border, irregular surface, or
    irregular coloration
Other clues: darkening of a pigmented
    lesion, development of pigmented
    satellite lesions, irregular margins or
    surface elevations, notching, recent
    or rapid enlargement, erosion or
    ulceration of surface, pruritus

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What are the “ABCDs” of
melanoma?
P472

Asymmetry
Border irregularity
Color variation
Diameter >6 mm and Dark lesion

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What are the associated risk
factors?
P472

Severe sunburn before age 18, giant
congenital nevi, family history, race
(White), ultraviolet radiation (sun),
multiple dysplastic nevi

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How does location differ in
men and women?
P472

Men get more lesions on the trunk;

women on the extremities

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Which locations are
unusual?
P472

Noncutaneous regions, such as mucous
membranes of the vulva/vagina, anorectum,
esophagus, and choroidal layer of the eye

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What is the most common
site of melanoma in men?
P472

Back (33%)

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What is the most common
site of melanoma in women?
P472

Legs (33%)

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What are the four major
histologic types?
P472

Superficial spreading
Lentigo maligna
Acral lentiginous
Nodular

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Define the following terms:
Superficial spreading melanoma
P472

Occurs in both sun-exposed and
non-exposed areas; most common
of all melanomas (75%)

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Define the following terms:
Lentigo maligna melanoma
P473

Malignant cells that are superficial, found
    usually in elderly patients on the head
    or neck
Called “Hutchinson’s freckle” if
    noninvasive
Least aggressive type; very good
    prognosis
Accounts for < 10% of all melanomas

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Define the following terms:
Acral lentiginous melanoma
P473

Occurs on the palms, soles, subungual
    areas, and mucous membranes
Accounts for ≈5% of all melanomas
    (most common melanoma in
    African American patients; ≈50%)

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Define the following terms:
Nodular melanoma
P473

Vertical growth predominates
Lesions are usually dark
Most aggressive type/worst prognosis
Accounts for ≈15% of all melanomas

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Define the following terms:
Amelanotic melanoma
P473

Melanoma from melanocytes but with

obvious lack of pigment

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What is the most common
type of melanoma?
P473

Superficial spreading (≈75%) (Think:
SUPERficial = SUPERior)

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What type of melanoma
arises in Hutchinson’s
freckle?
P473

Lentigo maligna melanoma

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What is Hutchinson’s
freckle?
P473

Lentigo maligna melanoma in the radial
growth phase without vertical extension
(noninvasive); usually occurs on the
faces of elderly women

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STAGING
What are the American Joint Committee on Cancer
(AJCC) stages simplified:
IA?
P473

<1 mm without ulceration

STAGING
What are the American Joint Committee on Cancer
(AJCC) stages simplified:
IR?
P473

<1 mm with ulceration or 1–2 mm

without ulceration

STAGING
What are the American Joint Committee on Cancer
(AJCC) stages simplified:

P474

1–2 mm with ulceration or 2–4 mm

without ulceration

STAGING
What are the American Joint Committee on Cancer
(AJCC) stages simplified:
IIB?
P474

2–4 mm with ulceration or >4 mm

without ulceration

``` STAGING What are the American Joint Committee on Cancer (AJCC) stages simplified: IIC? P474 ```

>4 mm with ulceration

``` STAGING What are the American Joint Committee on Cancer (AJCC) stages simplified: III? P474 ```

Positive nodes

``` STAGING What are the American Joint Committee on Cancer (AJCC) stages simplified: IV? P474 ```

Distant metastases

STAGING What are the common sites of metastasis? P474

``` Nodes (local) Distant: lung, liver, bone, heart, and brain Melanoma has a specific attraction for small bowel mucosa and distant cutaneous sites Brain metastases are a common cause of death ```

STAGING What are the metastatic routes? P474

Both lymphatic and hematogenous

STAGING How is the diagnosis made? P474

Excisional biopsy (complete removal leaving only normal tissue) or incisioned biopsy for very large lesions (Note: Early diagnosis is crucial)

STAGING What is the role of shave biopsy? P474

No role

STAGING What is the “sentinel node” biopsy? P474

Inject Lymphazurin® blue dye, colloid with a radiolabel, or both around the melanoma; the first LN in the draining chain is identified as the “sentinel lymph node” and reflects the metastatic status of the group of lymph nodes

STAGING When is elective lymph node dissection recommended? P474

Controversial—possible advantage in melanomas 1 to 2 mm in depth but jury still out; sentinel node biopsy if >1 mm is becoming very common

STAGING What is the recommended size of the surgical margin for depth of invasion: Melanoma in situ? P475

0.5-cm margin

``` STAGING What is the recommended size of the surgical margin for depth of invasion: ≤1 mm thick? P475 ```

1-cm margin

``` STAGING What is the recommended size of the surgical margin for depth of invasion: 1–4 mm thick? P475 ```

2-cm margin

``` STAGING What is the recommended size of the surgical margin for depth of invasion: >4 mm thick? P475 ```

3-cm margin

STAGING What is the treatment for digital melanoma? P475

Amputation

``` STAGING What is the treatment of palpable lymph node metastasis? P475 ```

Lymphadenectomy

STAGING What factors determine the prognosis? P475

``` Depth of invasion and metastasis are the most important factors (Superficial spreading and lentigo maligna have a better prognosis because they have a longer horizontal phase of growth and are thus diagnosed at an earlier stage; nodular has the worst prognosis because it grows predominantly vertically and metastasizes earlier) ```

``` STAGING What is the workup to survey for metastasis in the patient with melanoma? P475 ```

Physical exam, LFTs, CXR (bone | scan/CT/MRI reserved for symptoms)

STAGING What is the treatment of intestinal metastasis? P475

Surgical resection to prevent | bleeding/obstruction

``` STAGING Which malignancy is most likely to metastasize to the bowel? P475 ```

Melanoma

``` STAGING What is the surgical treatment of nodal metastasis? P475 ```

Lymphadenectomy

STAGING What is FDA-approved adjuvant therapy? P475

Interferon alpha-2b (for stages IIB/III)

STAGING What is the treatment of unresectable brain metastasis? P476

Radiation

STAGING What is the treatment of isolated adrenal metastasis? P476

Surgical resection

STAGING What is the treatment of isolated lung metastasis? P476

Surgical resection

STAGING What is the most common symptom of anal melanoma? P476

Bleeding

STAGING What is the treatment of anal melanoma? P476

APR or wide excision (no survival benefit | from APR, but better local control)

``` STAGING What other experimental therapy is available for metastatic disease? P476 ```

1. Monoclonal antibodies 2. Chemotherapy (e.g., dacarbazine) 3. Vaccinations

STAGING What is the median survival with distant metastasis? P476

≈6 months