Melanoma

1
Melanoma

• Dr.Erich Flögel
• Fresenius Kabi Austria
• Infections, Oncology

2
Melanoma

• Almost 30 of all melanomas arise in the head and
  neck
• Widespread use of sunscreen has not lowered the
  incidence.
• Incidence is increasing almost 5 per year
• Approximately 47,000 new cases in 2001

3
Predisposing Factors

• Sun Exposure
• Age, frequency, severity of exposure may play a
  role
• Sunscreen use may not be protective
• Familial Melanoma / DNS
• Family members have almost 50 chance of
  developing melanoma
• Lesions may be multiple and in sun shielded areas
• Xeroderma Pigmentosa
• Predisposes to several types of skin cancer
• Skin malignancies often appear by age 10

4
Sunlight

• UVB (280-320nm)
• Causes direct DNA damage
• Originally thought to be primary factor
• Blocked by current sunscreens
• UVA (320-400nm)
• Causes indirect DNA damage via free radicals
• Some now consider as more important than UVB
• Sunscreen has little UVA protection

5
Types of Melanoma

• Superficial Spreading
• Most common
• Cells atypical but uniform in appearance
• Nodular
• Early invasion due to vertical growth
• Acral Lentiginous
• Appears on palms and soles
• Histology shows heavily pigmented dendritic
  processes in the basal layer

6
Types of Melanoma

• Desmoplastic
• May lack pigment
• Peri-neural invasion is classic
• Histologic exam may show school of fish
  appearance
• Lentigo Maligna Melanoma
• May remain in-situ for decades
• Can spread along hair follicles
• Mucosal
• Often lack melanin
• Conventional staging system does not apply
• Site of lesion corresponds to prognosis
• Nasal cavity best prognosis, 31 at 5-yrs
• Paranasal sinuses worst prognosis, 0 at 5-yrs

7
Diagnosis

• History
• Family History
• Sun exposure
• Bleeding, pain
• Physical
• ABCD
• Histology
• HE
• S-100, HMB-45

8
Biopsy

• Excisional
• Recommended for small lesions
• Margins of 2mm
• Incisional
• For larger lesions
• Does not alter draining lymphatics
• Punch
• Same as incisional
• Shave
• Contraindicated
• Needle
• Contraindicated

9
Clark staging

• Based upon histologic level of invasion
• Level I Epidermis only (in situ)
• Level II Invades the papillary dermis, but not
  to the papillary-reticular interface
• Level III Invades to the papillary-reticular
  interface, but not into the reticular dermis
• Level IV Into the reticular dermis
• Level V Into subcutaneous tissue

10
Breslow staging

• Based upon absolute depth of invasion
• Stage I lt 0.75 mm
• Stage II 0.76 1.5 mm
• Stage III 1.51 4.0 mm
• Stage IV - gt 4.0 mm

11
AJCC staging
12
AJCC staging
13
AJCC staging
14
Prognosis by AJCC stage

• Stage I
• lt 0.75 96
• 0.75 1.5 87
• Stage II
• 1.5 2.49 75
• 2.5 3.99 66
• gt 4.0 47
• Stage III
• One node 45
• Two nodes lt 20
• Stage IV
• 8 10
• Percentages are five year survival except stage
  IV lesions which represent one year survival

15
(No Transcript)
16
Treatment - Stage I

• Labs
• LDH
• Radiology
• CXR
• Excision
• 1 cm margins
• Adjunctive Therapy
• None

17
Treatment - Stage II

• Labs
• LDH
• Radiology
• CXR
• Possible CT for metastasis
• Possible Lymphoscintigraphy
• Excision
• 2 cm margins
• Adjunctive Therapy
• Possible elective neck dissection
• Possible sentinel lymph node biopsy
• Possible elective radiation

18
Treatment - Stage III

• Labs
• LDH
• Possible LFTs
• Radiology
• CXR
• CT neck
• Possible CT abdomen, MRI brain
• Excision
• 2 cm margins
• Remove in-transit lymphatic basins
• Neck dissection directed by site
• Posterolateral vs. Lateral vs. Supraomohyoid
• Adjunctive Therapy
• Probable radiotherapy
• Possible chemotherapy

19
Treatment - Stage IV

• Labs
• CBC, LFTs, LDH
• Radiology
• CT Chest, Abdomen, Pelvis
• MRI brain
• Excision
• 2 cm margins
• Remove in-transit lymphatic basins
• Neck dissection directed by site
• Posterolateral vs. Lateral vs. Supraomohyoid
• Adjunctive Therapy
• Radiation therapy
• Consider chemotherapy as part of a clinical trial

20
Neck Dissection
21
Neck Dissection

• Posterolateral ND
• Lesions in occipital and posterior scalp areas
• Lateral ND
• Lesions on temple, forehead, anterior scalp
• Supraomohyoid
• Lesions of anterior face

22
Follow-up
23
Sentinel Lymph Node Biopsy

• Used to determine nodal status in low-risk tumors
• Allows for limited surgical morbidity.
• Has prognostic value for patient outcome

24
Sentinel Lymph Node Biopsy

• Procedure
• Preoperative lymph basin mapping using
  lymphscintigraphy with Tc99
• Preoperative injection of radiotracer allows for
  intraoperative gamma counter localization
• Intraoperative injection of iosulfan blue allows
  for visual detection of involved nodes.
• Allows for detection of sentinel nodes in 88-99
  of patients depending on the study cited.

25
Sentinel Lymph Node Biopsy

• Incidence of positive SLNB 12
• False negative rate lt 2
• Three year survival rates for negative vs.
  positive SLNB were 96.8 and 69.9, respectively
  
• Multivariate analysis has shown that positive
  SLNB predicts survival more accurately than depth
• Elective neck dissection has not been found to
  change outcome if SLNB is negative
• Positive SLNB patients may be candidates for
  radiation therapy

26
Sentinel Lymph Node Biopsy

• Recurrence following negative SLNB is most
  commonly in the assesed lymphatics.
• Gershenwald found that 80 of his regional
  recurrences actually had melanoma in the biopsied
  gland, but were missed on analysis
• Use of S-100 or HMB-45 increases the diagnostic
  value and may lower the false negative rate.

27
Radiation

• Indications include stage III or IV lesions
• Patients with positive SLNB should be considered
• Decreases local recurrence rates to 85-88
• Does not affect overall survival
• May be contraindicated for lesions near the eye
  or for midline lesions

28
Chemotherapy

• Numerous therapy modalities exist
• No significant benefit has been found for any
  therapy to date
• Administration of chemotherapy should be done as
  part of an ongoing clinical trial.