Melanoma and Merkel Cell tumours - PowerPoint PPT Presentation

1 / 65
About This Presentation
Title:

Melanoma and Merkel Cell tumours

Description:

metastatic carcinoid. amelanotic small cell melanoma. Immuno-reagents. Management. Excision ... Metastatic disease. Follow up. q 3mo for one year ... – PowerPoint PPT presentation

Number of Views:999
Avg rating:3.0/5.0
Slides: 66
Provided by: treforn
Category:

less

Transcript and Presenter's Notes

Title: Melanoma and Merkel Cell tumours


1
Melanoma and Merkel Cell tumours
  • Trefor Nodwell MDCM
  • Resident Plastic Surgery
  • Dalhousie University

2
Outline
  • Introduction The Melanocyte and melanoma
  • Epidemiology
  • Risk Factors
  • Clinical Presentation
  • Approach to suspicious lesions
  • Growth Patterns

3
Outline
  • Workup
  • Staging/Prognostic Factors
  • Surgical Options
  • Adjuvant Therapy

4
Outline
  • Merkel Cell Tumours
  • Definition
  • Epidemiology
  • Presentation
  • Prognosis
  • Risk Factors
  • Histology
  • Management

5
Introduction
  • Embryology-
  • ectodermal derivatives
  • epidermis, pilo-sebaceous and apocrine units
    eccrine sweat glands, nail units
  • Neuroectoderm
  • melanocytes, nerves, sensory receptors
  • Mesoderm
  • macrophages, mast cells, Langerhans cells, Merkel
    cells, fibroblasts, blood and lymph vessels, fat
    cells.

6
Introduction
  • Epidemiology
  • 2 of all cancers
  • 2nd to lung Cancer in Women
  • Incidence Doubling every decade
  • 1925 1.1/100 000, 1975 6.2/100 000
  • 40 000 new cases per year in the US

7
Introduction
  • Canadian Cancer Society estimates
  • 2001 - 3,800 new cases
  • Nova Scotia 22/100 000 males, 17/100 000 females
  • 1985 1135
  • 2000 174

8
Risk Factors
  • Phenotype
  • Light skin
  • Numerous nevi (/- dysplastic)
  • Burn easily
  • Blue-green, grey eyes
  • blond/red hair
  • Freckling
  • Family History

9
Risk Factors
  • Sun Exposure

10
Introduction
11
Phototypes
12
Risk Factors
  • Genetic Predisposition
  • Xeroderma Pigmentosum
  • Familial Atypical Multimole Melanoma
  • Sun Exposure
  • Chemical induction (Petroleum Products)
  • Trauma (Soles of feet)
  • hormonal (pregnancy)

13
Introduction
  • Genetics
  • Tumour Suppressor Gene p16 on Ch 9p21
  • Growth factors
  • Epidermal, Nerve, Insulin-like, fibroblast,
    platelet derived, transforming growth factor beta

14
Differential
  • Dysplastic Nevi (BK Moles, Clarks Nevus)
  • Poor terminology
  • Potential precursors to MM
  • Solitary Risk doubles
  • gt10 Risk 12-fold

15
Differential
  • Congenital Nevi
  • Present at birth
  • No Clear histological definition
  • Nevomelanocytes
  • Large 20cm
  • Spitz Nevus (aka Juvenile Melanoma)

16
Clinical Presentation
  • American Cancer Society ABCDs of melanoma
  • Asymmetric
  • Border irregularity
  • Colour variability
  • Diameter gt 6mm.

17
Clinical Presentation
  • Be suspicious of lesions that change in
  • size
  • colour
  • elevation
  • Pruritis
  • Bleeding
  • Ulceration

18
Clinical Presentation
  • Region
  • Women lower limbs
  • Men Trunk
  • 20-50 arise from preexisting nevi

19
Approach to suspicious lesions
  • Clinical Diagnosis
  • Management
  • Markers for patients at risk for Melanoma
  • Excise- changing lesions, atypical lesions
  • Routine self and physician exam

20
Approach to suspicious lesions
  • Excisional biopsy
  • lt2cm dia.
  • Representative Incisional biopsy
  • Larger lesions
  • thickest portion
  • most typical part
  • transition zone

21
Growth Patterns
  • Superficial Spreading
  • Nodular
  • Lentigo Maligna
  • Acral Lentiginous (acro lentiginous)
  • BANS

22
Growth Patterns
  • Superficial spreading
  • 70-80 of MM
  • Slow growing
  • Variable colour
  • Lower metastatic potential

23
Growth Patterns
  • Nodular
  • aggressive, develop rapidly
  • Usually arise denovo
  • Vertical growth
  • Typical appearance
  • easily detected

24
Growth Patterns
  • Lentigo Maligna Melanoma
  • Pigmented lesions in sun damaged skin (Face)
  • large irregular borders
  • Notched

25
Growth Patterns
  • Acral Lentiginous
  • Palms, soles, nail bed
  • All ALMs occur on extremities
  • Large, slow growing
  • 50-60 yo
  • Big toe and thumb

26
Staging
  • Clark
  • level I
  • lesions involving only the epidermis (in situ
    melanoma)not an invasive lesion
  • level II
  • invasion of the papillary dermis, but does not
    reach thepapillary-reticular dermal interface
  • level III
  • invasion fills and expands the papillary dermis,
    but does notpenetrate the reticular dermis
  • Breslow
  • mm thickness at thickest portion
  • top of granular cell layer to base of malignant
    cell
  • Other (mitoses, atypia, nests, neural invasion,
    inflammatory cells)

27
Staging
  • level IV
  • invasion into the reticular dermis but not into
    the subcutaneoustissue
  • level V invasion through the reticular dermis
    into the subcutaneous tissue

28
Staging
  • Breslow
  • thickness 0.75 mm or less
  • thickness 0.76 mm to 1.50 mm
  • thickness 1.51 mm to 4.0 mm
  • thickness 4.0 mm or greater

29
Staging
  • AJCC TNM Classification
  • pTx unable to assess
  • pT0 no primary
  • pT1 lt0.75mm, Clarks II
  • pT2 0.75-1.5 mm,III
  • pT3 1.5-4 mm, IV
  • pT4gt4mm, /- satellites, V

30
Staging
  • Regional lymph nodes (N)
  • NX cannot be assessed
  • N0 No node metastasis
  • N1 Metastasis 3 cm or less
  • N2 Metastasis more than 3 cm and/or in-transit
    metastasis
  • N2a Metastasis more than 3 cm in greatest
    dimension
  • N2b In-transit metastasisN2c Both (N2a and
    N2b)

31
Staging
  • Distant metastasis (M)
  • MX Distant metastasis cannot be assessedM0 No
    distant metastasisM1 Distant metastasis
  • M1a Metastasis in skin or subcutaneous tissue or
    lymph node(s) beyond the regional lymph
    nodesM1b Visceral metastasis

32
Staging
  • AJCC Groupings
  • Stage 0
  • pTis, N0, M0
  • Stage I
  • pT1, N0, M0pT2, N0, M0
  • Stage II
  • pT3, N0, M0

33
Staging
  • Stage III
  • pT4, N0, M0Any pT, N1, M0Any pT, N2, M0
  • Stage IV
  • Any pT, Any N, M1

34
Metastatic Workup
  • Physical Exam
  • Adjuvant tests
  • Liver tests
  • Chest X-ray
  • limited CT scanning

35
Prognostic Factors
  • Clinical
  • Female sex better
  • Older, worse
  • Extremities better than trunk or scalp
  • Histologic
  • vertical thickness

36
Prognostic Factors
37
Prognostic Factors
  • Nodal Involvement
  • Ulceration
  • Mitotic Number

38
Management
  • Early diagnosis
  • Prompt excision, within 21 days.
  • Margins
  • In situ 0.5cm (1992 NIH Consensus)
  • MM lt1mm thick 1cm is safe
  • MM 1.5-4.0 mm thick, 2cm
  • MMgt4mm 2-3cm.

39
Lymphadenectomy
  • Therapeutic
  • for palpable disease- always indicated
  • lt2cm 5 year survival 46
  • Elective LND
  • controversial, conflicting studies

40
Sentinel Node Biopsy
  • Indications
  • truncal melanoma lt0.76mm
  • all melanomas 0.76-1.0
  • male patients with thin, Clarks III ulcerated
    lesions
  • Intermediate thickness MM

41
Sentinel Node Biopsy
  • Preoperative technitium
  • Vital blue dye
  • Gamma probe intra-op
  • Histological exam of the entire node
  • May obviate the need for ELND

42
Recurrence
  • Stage I and II - 2.5-3.2 rate
  • 80 within 3 years
  • Remainder over 15-20 years.
  • Local recurrence
  • In-transit mets

43
Recurrence
  • Treatment
  • excision- for single lesions only
  • regional limb perfusion
  • intra-arterial or systemic chemotherapy
  • Radiation - reserved for poor surgical candidates

44
Metastases
  • Stage I and II - 34 months
  • Stage III lt12months
  • Median survival 6months
  • Five year survival 6

45
Metastases
  • Sites
  • Lymph nodes, Skin and subcutaneous 59
  • Lungs- 36
  • Liver 20
  • Brain
  • 20
  • Bone 17
  • GI 7

46
Adjuvant therapies
  • To compliment surgical excision
  • Immunotherapy
  • Interferon alpha 2b
  • Vaccines
  • BCG
  • Chemotherapy
  • Dacarbazine based
  • 10-20 response rate

47
Adjuvant therapies
  • Intra-arterial Perfusion
  • 30 year experience
  • Melphalan directly into the vasculature
  • Hyperthermic Perfusion
  • 38-40degrees
  • DTIC or Melphalan

48
Prevention!!
49
Merkel Cell Carcinoma
50
History
  • Touch Cell (Tastzellen) 1875
  • Uncertain histogenisis
  • Trabecular Carcinoma of the Skin 1972

51
Epidemiology
  • 400 cases/year in the US
  • 100 times more rare than Melanoma
  • 26 fatality

52
Clinical Presentation
  • Nonspecific
  • Sun exposed skin
  • Caucasian
  • DDx
  • SCC, BCC, Keratoacanthoma, MM

53
Clinical Presentation
  • Head and Neck 40
  • Upper extremity 19
  • MaleFemale 32
  • Age at diagnosis
  • Mean 66 years
  • 2/3 are over 60.

54
Prognosis
  • Early Disease 90 5 year survival

55
Risk Factors
  • Prolonged Sun Exposure
  • Agegt60
  • PUVA
  • Arsenic (Fowlers)
  • Immunosuppression

56
Histology
  • Full thickness dermis
  • subcutaneous fat and muscle
  • epidermal ulceration
  • Associated actinic elastosis

57
Histology
  • Subtypes
  • Intermediate
  • Small Cell
  • Trabecular narrow ribbons 1-2 cells thick
  • Diffuse sheets or nests
  • Scant cytoplasm
  • round/oval nuclei

58
Histology
  • Differential
  • metastatic small cell lung ca
  • lymphoma
  • metastatic carcinoid
  • amelanotic small cell melanoma
  • Immuno-reagents

59
Management
  • Excision
  • margins
  • 0.5 cm - 100 recurrence
  • 2.5cm - 49 recurrence
  • Mohs micrographic surgery
  • 50 recurrence

60
Management
  • Lymph nodes
  • ELND only independent variable for improved
    relapse free survival.
  • Sentinel node
  • Radiation therapy
  • improves disease free survival

61
Management
  • Radiation as adjuvant therapy

62
Management
  • Chemotherapy
  • No role as adjuvant therapy
  • Metastatic disease
  • Follow up
  • q 3mo for one year
  • 62 disease specific survival if recurrences
    treated aggressively

63
Summary
  • Highest grade variant of skin cancer
  • 100 times more rare than melanoma
  • nonspecific appearance
  • immuno-histochemistry
  • Treatment

64
Summary
  • Excise
  • Nodes
  • Radiation
  • chemotherapy

65
THE END
Write a Comment
User Comments (0)
About PowerShow.com