Melanoma FRCR CO2A Flashcards
origin of melanocytes and its migration
neural crest and migrates to basal layer of the epidermis and the uveal tract
Types of cutaneous melanoma
- superficial spreading
- nodular
- acral lentiginous
- lentigo maligna melanoma
Reason for rise in MM
- increased detection
- excessive recreational exposure to sunlight
peak incidence and commonly affected race
4th and 5th decade
white>non white (10 x)
RFs for Melanoma
- UV rad exp’
- skin type: fair skin with blond or red hair
- no of common naevi
- family hx
- CDKN2A : inherited germline mutation
6 . PUVA treatment
Protective Role
Vitamin D
Prevention strategies
- spend time in the shade between 11 am to 3 pm
- avoid getting sunburnt
- cover up with a hat, t shirt and sunglasses
- take extra care with sun protection for children
- SPF 15 sunscreen
Pathology of mlenoma
atypical melanocytes that infiltrates into the dermis
no of mitoses, LVSI and regression
feature of superficial spreading melanoma
- 70%
- pigmented lesions often flat or with slight elevation, irregular border and irregular pigmentation
- micro: dominant horizontal growth
Nodular melanoma features:
- 15% of cases
- raised, nodular lesion, blue - grey to completely amelanocytic
- a/w ulceration / bleeding
- micro : no or minimal horizontal growth but ext dermal invasion
Acral lentiginous melanoma features?
- 10 % of cases
- palms, soles, subungual regions (great toe, thumb)
- less related to UV exp
- micro: acanthosis of epidermis, atypical melanocytes
lenti maligna melanoma (LMM)
5%
older pts usually on face
chronic sun exposure
precursor lesion: Hutchinson’s freckle, 5 % progress to LMM
Breslow thickness
measures the depth of a melanoma tumor from the surface of the skin to the deepest point of the tumor cells, and is measured in millimeters
Breslow thickness staging
Tis: Melanoma cells are only in the very top layer of the skin (epidermis).
T1: Melanoma is 1mm thick or less.
T2: Melanoma is between 1mm and 2mm thick.
T3: Melanoma is between 2mm and 4mm thick.
T4: Melanoma is more than 4mm thick.
spread of Melanoma
skin, subcut tissues and LNs
local spread of melanoma
initially, horizontal growth f/b vertical growth through dermis
Satellite nodules and in transit nodules
satellites nodules: cut or subcut nodules less than 2 cm from primary tumor
in transit nodules: beyond 2 cm but not beyond the draining LNs
metastatic spread of melanoma
Lung
Liver Bone
Brain
small bowel
meninges
GB
adrenals
main c/f of cut melanoma
pigmented lesion with an irregular edge and irregular pigmentation
ABCDE rule for melanoma
examination rule
A: Asymmetry
B: Boder irregular
C: Color irregular
D: Diameter > 5 mm
E: Elevation
Revised 7 point check list
Major Features:
1. change in size of lesion
2. irregular pigmentation
3. irregular border
Minor features
1. inflammation
2. largest diameter 7 mm or greater
3. OOzing crusting or bleeding
D/D of melanoma
- basal cell papilloma
- pigmented BCC
- thrombosed angioma
- pyogenic granuloma
- Dermatofibroma
Investigations and Staging of melanoma
- Dermatoscopy:
- excision of the lesion s/times incisional
- C/E of LNs
margin requirement as per lesion size
< 1 mm: 1 cm
1 - 2 mm: 1-2 cm
2 - 4 cm : 2 - 3 cm
> 4 cm : 3 cm
Surgery for localized cut melanoma
Wide excision of primary lesion, margin depends on breslow thickness
Elective Lymph Nodal Dissection (ELND)
in presence of SLNB positive
when is therapeutic complete node dissection advised in melanoma
clinically palpable nodal disease
current UK practise for SLNB
Melanoma > 1 mm
Stage IA adjuvant Rx
observation
Stage IB Adjuvant Rx
depends on SLN report, if negative observation
if +, further work up
stage Ib or II
adjuvant Pembrolizumab
(category 1)
- Nivolumab (category 1)
stage IIIA/IIIB/IIIC adjuvant treatment
Nivolumab
Pembrolizumab
Dabrafenib/
trametinib if BRAF V600 mutation
positive
stage wise 5 yr OS
I: 91 %
II: 64 %
III: 40 %
Prognostic factors at time of presentation:
- Tumor Thickness
- Ulceration
- LNs
- gender (female better than males)
- Anatomical location (extremities better than face)
- Age
Role of RT in melanoma
SRT/SRS for brain mets
metastatic melanoma Rx
Nivolumab/ipilimumab (category 1)
Nivolumab and relatlimab
(category 1)
- Anti-PD-1 monotherapyd,f,g
Pembrolizumab (category 1)
Nivolumab (category 1)
Other recommended regimens
* Combination targeted therapy if BRAF
V600 mutation positive
Dabrafenib/trametinib (category 1)
Vemurafenib/cobimetinib (category 1)
Encorafenib/binimetinib (category 1)
- Pembrolizumab/low-dose ipilimumabo
(category 2B)
