Melanoma NM Flashcards
Melanoma T
Melanoma N
Melanoma M
Non cutaneous mucosal melanoma
Mucosal surface of GIT or vagina or urethra
1.3%
Surgery + radio
Non cutaneous ocular melanoma
Uveal, choroidal
5.5%
Surgery + radio
Cutaneous melanoma %
95%
Melanoma risk
Xeroderma pigmentosum
Familial atypical mole melanoma sy
Sun exposure
Fair skin phenotype
History of nevi
Prognosis for localised tumor <1 mm
> 90% 5-year survival
Prognosis for localised tumor >1mm
50-90% 5-year survival
Recurrence
50% regional LN
30% distant MTS
20% local (stage I or II)
Distant MTS
Skin
Lung
Brain
Bone
Liver, spleen
GIT
US
Regional LN in stage Ib-IIIa
FDG
Distant MTS
> CT in extracerebellar MTS
Not generally accepted as a standard imaging modality for all stages
High sensitivity for IIIb/IIIc
CT, MRI and FDG in early stage
Very low accuracy
False-positive
Useful for stage III and IV
SLNB indication
After histological confirmation and wide local excision + 1-2 cm margins
Beyond stage IB >T1b
Clinically LN negative
Breslow 1-4mm
MRI
Higher spatial resolution
Better in intracranial, bone marrow, hepatic, soft tissue involvement
Whole body MR - best for multiple cutaneous melanoma, even >PET
Clinically occult LN MTS
Non palpable and difficult to identify with US
20% of patients with melanoma >1 mm
Most common sites of MTS
Regional LN
SLNB should be offered
Thin (<1 mm) and high risk (ulceration, mitotic rate >1 mm^2 or >50% regression)
Also for >4 mm or unknown thickness
Contra SLNB
Poor general health status
Local or systemic spread
Prior extensive surgery
Stage IB
T1b
T2a
Melanoma lab
Increased LDH
Predictor of survival / outcome in stage IV
Therapy
Inhibitor BRAF - - shrinkage of lesion
Monoclonal AB targeting CTLA4 and PD1
FDG response to treatment
Rapid uptake reduction - - good response
No early reduction - - refractory disease
Flare response to immunotherapy, but early detection of toxicity
For anti-PD1 later imaging better assessment
Predicted lymphatic drainage
98% lower limbs
88% upper limbs
56% anterior thorax
39% posterior trunk
Unpredictable in head and neck
SLNB technic
1 cm from melanoma intradermally
Raise a wheal
Volume 0.1-0.2 ml to avoid lymphatic collapse
5-120 MBq
10% rule
All LN counting 10% or higher than ex vivo hottest SLN should be harvested
Multiple basins
Torso, head, neck
Less favourable survival
Most important prognostic factor
Tumor thickness
Location
Ulceration
Mitotic rate
Positive LN
LDH
Older age
ABCDE criteria
A - assymetry
B - border irregularity
C - color
D - diameter >6mm
E - evolution over time
Margins
Stage 0 - 0.5 cm
Stage I - 1-2 cm
PET positive prediction
Mitotic rate >3 mm^2
T4
Lymphadenopathy
Bleeding
PET recommended
Positive SLNB
High risk
False positive FDG to cytokine therapy
Increased metabolism in normal lymph tissue (tonsils, LN)
FDG pseudo progression
immune infiltrates
Breslow <4 mm
> 75% no LN
LN in subcapsular region
Most commonly involved in MTS
Not frozen section
Immunohistochemistry
