Melanoma / Skin Cancer

Melanomas are malignant tumors of melanin producing cells (Melanocytes)

Third most common malignant tumor in UK


Common in females


Affects elderly population (Above 40 years), but nowadays it is increasingly affecting younger people


95% of the melanomas are confined to the skin, but they can also occur in extracutaneous sites like eyes, gastrointestinal tract, genitourinary tract, CNS and in lymph nodes.


Melanomas can occur anywhere in the body, most commonly in areas exposed to sun. But it can also occur in areas like palms, soles and nail beds.



Risk Factors
  

  1. Pale skin / fair skin
  2. Family history of melanoma
  3. Presence of moles, freckles
  4. Intermittent intense exposure to the sun
  5. Sun burns 
 
 
Growth Phases Of Melanoma
 
According to Clark, there are two growth phases
  1. Radial growth phase
    • Spread along the dermal-epidermal junction
    • Lesion is confined to the epidermis
  2. Vertical growth phase
    • Invade deep structures
    • Develop nodules – Nodular type
    • Poor prognosis


Types Of Melanoma 
  
  1. Superficial spreading (70%)
    • Seen on sun exposed areas 
      • In women – Lower legs
      • In men – Upper back 
    • Arise de novo or on pre existing naevus
    • Appears as an irregular brown, black or bluish black lesion associated with inflammation 
    • Initially grows radially then vertically
    • When vertical invasion occurs – Become raised and ulcerated
  2. Nodular 
    • Most rapid growing and aggresive type
    • More common in males
    • Seen on the trunk and limbs
    • Vertical growth phase
    • Symmetrical, raised, firm, uniformly coloured lesion
    • Non pigmented nodule formation
    • Ulceration present
  3. Lentigo maligna 
    • Seen on sun exposed areas
    • Least malignant 
    • Has an in situ growth phase
    • Commonly present as irregular brown patch over the cheek
    • Less common metastasis
  4. Acral lentiginous 
    • Commonly seen in extremities – Palms and soles
  5. Amelanotic melanoma
    • Non pigmented 


Lesion Characteristics Of Melanoma (ABCDE System)

  1. Asymmetry in two axes
  2. Border irregularity
  3. Colour variation within the lesion
  4. Diameter more than 6mm 
  5. Evolution of lesion with time / Elevation / Enlargement 
 
 
Prognostic Indicators Of Melanoma
  • Breslow thickness
    • Best prognostic indicator
    • Measured by a ocular micometer to the nearest 0.1mm 
    • Measured from the overlying granular layer in the epidermis to the deepest easily identified tumor cell
  • Clark’s index
    • Not commonly used
    • Corresponds with the histological levels of cancer invasion 
 
Dermatoscopy performed by trained professionals in assessing the suspicious lesion, but excision biopsy and histological assessment remains the gold standard in assessing melanomas
Incisional biopsy should only be performed when excision is not possible, as incisional biopsies can be misleading.
 
 
Management Of Melanoma
  
  1. Treatment of cutaneous melanoma demands MDT as it requires access to dermatology, oncology and plastic surgery
  2. Excision biopsy and histopathological assessment 
  3. Assess the Breslow thickness – Helps in assess prognosis and planning of treatment
  4. Locoregional spread / Management of  lymph nodes 
    • Sentinal lymph node biopsy (Best method)
    • Ultrasound guided FNAC can also be performed
    • Not done for stage I, II, IIIA 
    • Involved lymph nodes are removed by block dissection 
  5. Radiotherapy also has a role in the management – Lentigo maligna melanoma responds well to RT
  6. For metastatic disease – Palliative care (Pain and ulceration)
    • Consider RT, CT, palliative surgery 


Staging Of Melanoma 
  
  1. Breslow thickness
  2. Ulceration 
  3. Sentinal node biopsy
  4. CT scan of head, chest, abdomen and pelvis
  5. LDH levels
* 3, 4, 5, are not done for stage I, II, IIIa
 
 
 
Surgical Excision Margins
 
Traditional excision with is 3 – 5 cm, but the recommendations are as follows….
 
 
The excision margins is finally confirmed at MDT
 
 
Histopathology report includes….
  • Ulceration
  • Thickness
  • Mitotic count
  • Margins of excision 
  • Histological subtype 
  • Pathological staging 
  • Growth phase 
  • Regression
  • Tumour-infiltrating lymphocytes
  • Lymphatic or vascular invasion
  • Perineural invasion 
  • Microsatellites


Prevention, Screening And Surveillance Of Melanoma
  
  1. Identification of patients with risk factors and make urgent referrals
    • The following patients should be referred urgent and kept on surveillance 
      • A new mole appearing after the onset of puberty which is changing in shape, colour or size
      •  A long-standing mole which is changing in shape, colour or size
      • Any mole which has three or more colours or has lost its symmetry
      • A mole which is itching or bleeding
      • Any new persistent skin lesion, that is growing or if pigmented or vascular in appearance, and if the diagnosis is not clear 
      • A new pigmented line in a nail with associated damage to the nail
      • A lesion growing under a nail
  2. Teach how to self examine to identify early changes 


Keeping Records Of Melanoma
 
The following points should be noted when examining a patient on surveillance 
  • History (the presence or absence of these changes should be recorded) 
    • Duration of the lesion 
    • Change in size
    • Change in colour 
    • Change in shape 
    • Symptoms (itching, bleeding etc.)
  • Examination 
    • Site 
    • • Size (maximum diameter) 
    • • Elevation (flat, palpable, nodular) 
    • • Description (irregular margins, irregular pigmentation and if ulceration is present) (Level III, Grade B)
 
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Medical on Miami
1 year ago

I agree with a lot of the points you made in this article. If you are looking for the Miami Physiotherapy, then visit Medical on Miami. I appreciate the work you have put into this and hope you continue writing on this subject.

The Pines Family Practice
1 year ago

Thanks for sharing the best information and suggestions, I love your content, and they are very nice and very useful to us. If you are looking for the best skin cancer screening, then visit The Pines Family Practice. I appreciate the work
you have put into this.

skymd
1 year ago

I admire this article for the well-researched content and excellent wording. I got so involved in this material that I couldn’t stop reading. I am impressed with your work and skill. If anyone interested to know more about the treatment of melanoma, Skymd is the best choice.

The Pines Family Practice
1 year ago

Thanks for sharing the best information and suggestions, I love your content, and they are very nice and very useful to us. If you are looking for the best skin cancer screening, then visit The Pines Family Practice. I appreciate the work you have put into this.

Medical on Miami
1 year ago

I agree with a lot of the points you made in this article. If you are looking for the Miami Physiotherapy, then visit Medical on Miami. I appreciate the work you have put into this and hope you continue writing on this subject.

skymd
1 year ago

I admire this article for the well-researched content and excellent wording. I got so involved in this material that I couldn’t stop reading. I am impressed with your work and skill. If anyone interested to know more about the treatment of melanoma, Skymd is the best choice.