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Malignant Melanoma

  1. Identify the high risk patients
    1. Family or personal history of melanoma.
    2. Skin type 1 or 2, easy to burn, difficult to tan.
    3. Tendency to freckle.
    4. History of severe sun burn.
    5. Many moles or presence of atypical nevi, clinically. (giant congenital melanocytic naevus)
  2. Identify the high risk lesions
     
    Symptoms:
    1. Changes in size, shape, height, colour of a lesion.
    2. Bleeding, erosion, ulceration, crusting and itching.
      Signs:
  3. The "abcde" of malignant melanoma
    1. Asymmetry
    2. Border irregularity
    3. Colour variegation
    4. Diameter greater than 6 mm
    5. Elevation
  4. Summary of clinical feature of malignant melanoma
  5. Superficial spreading melanoma
    1. Commonest variant.
    2. Site – any site. Predilection is back in men and the legs in females.
    3. Lesion presents as patchily pigmented macule with an irregular border.
  6. Lentigo maligna melanoma
    1. Occur on sun-damaged skin inelderly white.
    2. Presents as light brown macule with irregular border.
  7. Acral lentiginous melanoma
    1. Lesions are seen on palms and soles.
    2. Presents as pigmented macule with irregular border.
  8. Subungual melanoma
    1. Presents as discoloration of nail plate in addition there is discoloration.
    2. Of nail fold (hutchison’s sign).
  9. Nodular melanoma
    1. Most commonly seen on the trunk.
    2. Presents as rapidly growing papule, nodule that may show ulceration or crusting.
  10. Treatment: the multidisciplinary approach
     
    Surgical treatment of the primary lesion: wide local excision.
     
    The principle is to excise the lesion to the underlying muscle fascia with a margin of normal-appearing skin. That "safety margin" is still a controversial and continuously evolving issue, and the surgical guideline from AJCC is quoted here:

Breslow Depth

Excision Margin

< 0.75 Mm

1 Cm

0.76 Mm - 1.49 Mm

1 - 2 Cm

1.5 Mm - 4 Mm

1 - 2 Cm +/-ELND +/-Adjuvant Therapy

> 4 Mm

3 Cm =/-Adjuvant Therapy


The current thought is that a 1 cm margin is appropriate for all lesions but investigations for regional and visceral metastasis should be done for lesions thicker than 1.5 mm and adjuvant treatment should be considered.

 

ELND-Elective Lymph Node Dissection:

 

A controversial issue again and it entails resection of lymph nodes in the drainage region without clinical evidence of involvement. It increases morbidity and has never been proven to improve survival. It is probably not indicated in thin lesions (less than 1.5 mm). Morton’s blue dye technique may help to improve this procedure.

  1. Mohs Micrographic Surgery
     
    Not an established method but may be an alternative as an tissue saving technique for lesion on the face.
  2. Cryotherapy
     
    May be considered in lentigo maligna, and lentigo maligna melanoma.

  1. Therapy for Metastatic Disease
    1. Surgery: for metastatic lesions.
    2. Chemotherapy: dacarbazine is the most effective single agent.
    3. Isolation perfusion: for the treatment of in-transit metastasis.
    4. Radiotherapy: for palliative treatment of metastasis.
    5. Evolving modalities: melanoma vaccines
    6. Monoclonal antibodies
    7. Adoptive immunotherapy
    8. Gene thera​py
Distinguishing feature of atypical moles from benign acquired nevi
 

Clinical Feature

Clinically Atypical Moles

Benign Acquired Nevi

Color

Variable Mixtures Of Tan,

Uniformly Tan Or Brown

 

Brown, Black, Or Red/Pink

 

 

Within A Single Nevus; Nevi

 

 

May Look Very Different

 

 

Form Each Other

 

Shape

Irregular Borders;

Round; Sharp, Clear-Cut

Size

Usually>6mm In Diameter:

Usually<6 Mm In Diameter

 

May Be > 10 Mm;

 

 

Occasionally < 6 Mm

 

Number

Often Very Many (> 100)

In A Typical Adult, 10 To 40

 

 

Perhaps 15% Of Patients

 

 

Have No Nevi

 

Location

Sun-Exposed Areas; The Back

Generally On The Sun-

 

Is The Most Common Site,

Exposed Surfaces Of The

 

But Dysplastic Nevi May

Skin Above The Waist; The

 

Also Be Seen On The Scalp

Scalp, Breasts, And Buttock

 

Breasts, And Buttocks

Are Rarely Involved

 

DD Of Cutaneous Melanoma

Blue Nevus

Gunmetal Or Cerulean Blue, Blue-Gray, Stable Over

 

Time. One – Half Occur On Dorsa Of Hands And Feet.

 

Lesions Are Usually Single, Small, 3 Mm To < 1 Cm.

 

Must Be Distinguished From Nodular Melanoma.
 

Compound Nevus

Round Or Oval Shape, Well-Demarcated, Smooth- Bordered. May

 

Be Dome-Shaped Or Parillomatous; Colores Range From Flesh Colored To Very Dark Brown, With Individual Nevi

 

Being Relatively Homogeneous In Color
 

Hemangioma

Dome-Shaped Reddish, Purple, Blue Nodule,

 

Compression With A Glass Microscope Slide May

 

Result In Blanching. Must Be Distinguished From

 

Nodular Melanoma.
 

Junctional Nevus

Flat To Barely Raised Brown Lesion. Sharp Border.

 

Fine Pigmentary Stippling Visible, Especially Upon Magnification.
 

Lentigo

Flat, Uniformly Medium Or Dark Brown Lesion With
 

Juvenile

Sharp Border. Solar Lentigines Are Acquired
 

Solar

Lesions On Sites Of Chronic Solar Exposure (Faceand Backs Of Hands). Lesions Are 2 Mm To ≥ 1 Cm.

 

Solar Lentigines Have Reticulate
 

Pigmented Basal

Papular Border. May Have Central Ulceration.
 

Cell Carcinoma

Usually On A Sun-Exposed Surface In An Older Patient. Patient Usually Has Dark Brown Eyes And Dark Brown Or Black Hair.
 

Pigmented

Lesion Is Not Well Demarcated Visually, Is Firm,
 

Dermatofibroma

And Dimaples Downward When Compressed

 

Laterally. Usually On Extremities. Usually < 6 Mm.
 

Seborrheic

Rough, Sharp-Bordered Lesions That Feel Waxy Andkeratosis “Stuck On”. Range In Color From Flesh To Tan, To

 

Dark Brown. Presence Of Keratin Plugs In Surface Is Helpful For Discriminating Especially Dark Lesions From Melanoma.
 

Subungual

Maroon (Red-Brown) Coloration. As Lesion Ows


WHO – EORTC Classification For Lymphoma.





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