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Flashcards in Melanoma Deck (16):
1

Types of melanoma

1. Superficial spreading 2. Acral lentinginous 3. Lentigo 4. Nodular

2

Superficial spreading: common?, features

Most common form >70% Flat pigmented macule, asymmetrical Changing in shape, size and colour Risks: Intermittent intense sunburn on trunk and limbs

3

Features of acral letiginous

Not due to sun exposure Soles, palms, toes, fingers, nails More common in dark skinned individuals

4

Features of Lentigo

Associated with solar keratosis Uneven pigment, facial freckle, change in size, shape and colour High total UV exposure head and neck 1. Lentigo maligna = in situ phase 2. Lentigo maligna melanoma is the invasive stage

5

Features of nodular

Poor prognosis More rapid growth, vertical growth ++

6

Risk factors

1. Genetic 2. Phenotypes->blonde with red hair 3. Sunlight exposure++ 4. Pre-existing melanocytic lesion 5. History of skin cancer 6. ++Freckles 7. Sun bed 8. Immunosuppression

7

Clinical features

altered pigmented lesion (ABCDE signs) (common) >50 benign melanocytic naevi (common) atypical naevi (common) melanocytic lesion that does not resemble surrounding melanocytic naevi ('ugly duckling') (common) pigmented lesion, asymmetric appearance, ill-defined/irregular borders, colour variation (common) spontaneous bleeding or ulceration of a pigmented lesion (uncommon) constitutional symptoms (uncommon) bluish-white veil (uncommon) persistent single-nail melanonychia striata (uncommon) Hutchinson's sign (uncommon) fixed lymphadenopathy (uncommon) in-transit metastases (uncommon)

8

ABCDE of melanoma

Asymmetry Border irregularity Colour variation Diameter >6mm Evolution

9

Examination

1. Examine lesion 2. Look for lymphadenopathy 3. Look for other lesions, including freckles etc 4. General examination

10

Investigations

1. Dermatoscopy 2. Excisional biopsy ->2mm margins down to fat ->Only partial/punch/shave if excisional too difficult Consider->depending on result 1. SLN biopsy 2. LDH 3. CXR 4. Chest/abdo/pelvic CT 5. Brain imaging 6. BRAF

11

Management

1. Confirmed-> wide local excision 2. If >in situ with no LN involvement consider sentinal node biopsy 3. In metastatic Surgical excision of regional LN High dose interferon' Regional node radiation Clinical trial Stage 4: systemic immunotherapy, chemotherapy

12

Guidelines for wide local excision

1. Insitu-> 5mm margin 2. 1cm margin 3. 1-4mm-> 1-2cm 4. >4mm-> 2cm

13

Staging

Stage 0 In situ melanoma

Stage 1 Thin melanoma 2 mm in thickness

Stage 2 Thick melanoma >2mm 

Stage 3 Melanoma spread to involve local lymph nodes

Stage 4 Distant metastases have been detected

14

Patient instructions

1. Monitor skin and LN monthly, see doctor if any changes 2. F/U routine with dermatologist / 3-12 months 3. Skin care->Slip, slop, slap

15

Patient presents with black spot

1. Show me, when did you notice 2. How did you find it 3. Sudden/gradual 4. Have you always had spot there 5. Change in colour, size, spread, pain, bleeding, itching, other spots 6. Any trauma 7. Hx of skin cancer 8. How much sun exposure, burnt often, sunscreen, hat 9. Ever check skin for cancers Spread 10. Breathless, jaundice, abdominal pain 11. Back pain 12. Dizzy, fits, faints, blackouts, HA, numbness, weakness 13. Impaired vision 14. Urinary changes 15. Weight loss, lumps in groin/armpit Risk factors 16. Fair skin, red hair, blue/green eyes 17. Sun exposure, short intense 18. FHx 19. Other skin lesions->compound nevi, lentigo, solar keratoses, dysplastic nevi Other 20. Past medical history 21. Family history 22. Social 23. Drugs, smoking, alcohol 24. Allergies Differentials: Malignant melanoma, BCC, seberrheoic keratoses, benign nevus

16

Follow up

Stage 1: Annually, earlier if concerns

Stage 2+: 3-6 monthly for 3 years, 4-12 monthly for 2 years, yearly ongoing

Check site, lymph nodes, other lesions + general