Skin and soft tissue: Melanoma

Question 1

What is the definition of melanoma?

Answer 1

Malignant neoplasm of skin, arising from melanocytes

Question 2

What is the lifetime risk of developing melanoma?

Answer 2

≈ 5%

This indicates that approximately 1 in 20 individuals will be diagnosed with melanoma in their lifetime.

Question 3

What is the incidence rate of melanoma?

Answer 3

50/100,000 (1/2000)

This represents the number of new melanoma cases diagnosed per 100,000 individuals per year.

Question 4

What is the median age at diagnosis for melanoma?

Answer 4

50 years

This suggests that half of the cases are diagnosed before this age.

Question 5

At what age does melanoma rarely occur?

Answer 5

In children

Melanoma is uncommon in pediatric populations.

Question 6

What are the major risk factors for developing melanoma?

Answer 6

• Sun Exposure & UVB light
• History of intense intermittent sunburns
• Chronic accumulative sun exposure (e.g. occupational)

These risk factors highlight environmental influences and personal history related to sun exposure.

Question 7

In which areas do men typically develop melanoma?

Answer 7

Areas like back

This indicates a common site for melanoma in males.

Question 8

In which areas do women typically develop melanoma?

Answer 8

Areas like legs

This indicates a common site for melanoma in females.

Question 9

What is malignant melanoma?

Answer 9

A malignant neoplasm of skin, arising from melanocytes

Malignant melanoma is a serious form of skin cancer originating from pigment-producing cells.

Question 10

What percentage of all cancers in 15-35 year olds in NZ is caused by melanoma?

Answer 10

23%

This highlights the significant impact of melanoma on younger populations in New Zealand.

Question 11

What is the lifetime risk of New Zealanders developing melanoma?

Answer 11

Approximately 5%

This indicates a notable risk for individuals in New Zealand.

Question 12

Where is the worldwide incidence of melanoma highest?

Answer 12

New Zealand

New Zealand has one of the highest rates of melanoma globally.

Question 13

What is the incidence rate of melanoma in NZ per 100,000 people?

Answer 13

50-90 cases

This rate is significantly higher compared to 34 cases in Australia.

Question 14

What is the median age at diagnosis of melanoma?

Answer 14

50 years

This suggests that melanoma is commonly diagnosed in middle-aged individuals.

Question 15

What percentage of melanoma diagnoses occur in individuals aged 60-79 years?

Answer 15

38%

This age group is notably affected by melanoma.

Question 16

List the classifications of melanoma.

Answer 16

• Superficial spreading
• Nodular malignant
• Lentigo malignant melanoma
• Carpal lentiginous
• Desmoplastic malignant
• Non-cutaneous melanoma

These classifications help in understanding the different types of melanoma.

Question 17

What percentage of all melanomas do superficial spreading melanomas represent?

Answer 17

50-64%

This subtype is the most common form of melanoma.

Question 18

In which age group are superficial spreading melanomas most commonly seen?

Answer 18

Patients aged 20-60 years

This age range indicates a significant risk for younger adults.

Question 19

Where do superficial spreading melanomas commonly occur in women?

Answer 19

Lower leg

This area is particularly susceptible in female patients.

Question 20

Where do superficial spreading melanomas commonly occur in men?

Answer 20

Back

This indicates a gender difference in melanoma presentation.

Question 21

How long does it typically take for superficial spreading melanomas to develop?

Answer 21

1-7 years

This development timeline is important for monitoring skin changes.

Question 22

What is a characteristic growth pattern of superficial spreading melanomas?

Answer 22

Radial growth initially, then vertical growth

Understanding this growth pattern is crucial for early detection.

Question 23

What do nodular malignant melanomas represent in terms of percentage of all melanoma diagnoses?

Answer 23

28%

This shows the prevalence of this specific melanoma type.

Question 24

What is a common feature of nodular malignant melanomas?

Answer 24

Palpable, thicker, usually convex or raised shape

These characteristics help distinguish this subtype from others.

Question 25

Where are nodular malignant melanomas most often seen?

Answer 25

Head, neck, and trunk ## Footnote These areas are common sites for this type of melanoma.

Question 26

True or False: Nodular malignant melanomas often occur in pre-existing naevi.

Answer 26

False ## Footnote Nodular malignant melanomas typically arise de-novo.

Question 27

What is a typical appearance of nodular malignant melanomas?

Answer 27

Dome shaped, can resemble a blood blister ## Footnote This appearance can lead to misdiagnosis if not recognized.

Question 29

Where do nodular malignant melanomas most commonly occur?

Answer 29

On the head, neck, and trunk ## Footnote Nodular malignant melanomas are aggressive and often arise de novo.

Question 30

What is the prognosis for nodular malignant melanomas?

Answer 30

Months to less than five years ## Footnote They are aggressive with a short radial phase.

Question 31

What phase do nodular malignant melanomas have with no in situ changes?

Answer 31

Short radial phase ## Footnote They transition to very early vertical growth.

Question 32

Are positive lymph nodes more common in nodular malignant melanoma cases compared to other melanomas?

Answer 32

Yes ## Footnote This indicates a more aggressive behavior.

Question 33

From what do lentigo malignant melanomas arise?

Answer 33

Hutchinson’s melanotic freckles ## Footnote These freckles are considered pre-invasive (melanoma in situ).

Question 34

What percentage of cases do lentigo malignant melanomas represent?

Answer 34

Approximately 7% ## Footnote They are the least common type of melanoma.

Question 35

What is the typical appearance of lentigo malignant melanomas?

Answer 35

Blue-black flat lesion ## Footnote They are often found on the face and seen in elderly patients.

Question 36

What percentage of lentigo malignant melanomas will progress to invasive melanoma?

Answer 36

5% ## Footnote This progression occurs into the dermis.

Question 37

What is the prognosis for lentigo malignant melanomas?

Answer 37

5-20 years or more ## Footnote They are the least aggressive melanoma.

Question 38

What type of cells are seen histologically in lentigo malignant melanomas?

Answer 38

Spindle shaped cells ## Footnote They do not have pagetoid cells.

Question 39

What is a notable characteristic of lentigo malignant melanomas after excision?

Answer 39

High recurrence rate ## Footnote This is relevant for patient management.

Question 40

Where do acral lentiginous melanomas commonly occur?

Answer 40

Thick epidermis, especially on soles and palms ## Footnote They are also commonly found in subungual and perineal regions.

Question 41

In which demographic are acral lentiginous melanomas more common?

Answer 41

Dark-skinned races and manual workers ## Footnote This highlights a disparity in melanoma types across populations.

Question 42

What is the typical size of acral lentiginous melanomas at the time of diagnosis?

Answer 42

>3 cm ## Footnote They are often large at diagnosis.

Question 43

What is the histological feature of acral lentiginous melanomas?

Answer 43

Prolonged radial phase with large atypical melanocytes ## Footnote These melanocytes have long dendritic processes.

Question 44

What is the prognosis for acral lentiginous melanomas?

Answer 44

Poor: 1-10 years; 5-year survival is less than 20% ## Footnote This indicates a need for aggressive treatment.

Question 45

Where are desmoplastic malignant melanomas most commonly found?

Answer 45

Head and neck ## Footnote This region has a higher incidence of this melanoma type.

Question 46

What is the recurrence rate for desmoplastic malignant melanomas after surgical excision?

Answer 46

40-60% ## Footnote This indicates a need for careful monitoring.

Question 47

How does the incidence of metastases in desmoplastic malignant melanomas compare to other melanomas?

Answer 47

Lower incidence ## Footnote This may affect treatment decisions.

Question 48

Where can non-cutaneous melanomas occur?

Answer 48

Anywhere that neural crest cells migrate ## Footnote Locations include ocular, mucous membranes, genitalia, and anorectum.

Question 49

What percentage of non-cutaneous melanomas occur in the ocular region?

Answer 49

2-5% ## Footnote This highlights the variety of melanoma locations.

Question 50

What percentage of non-cutaneous melanomas occur in mucous membranes?

Answer 50

1-2% ## Footnote This indicates a less common site for melanoma.

Question 52

What are the two categories of risk factors for developing melanoma?

Answer 52

Host factors and environmental factors

Question 53

What is the approximate risk of developing melanoma for a 70-year-old in the next 10 years?

Answer 53

Approximately 2% ## Footnote This statistic highlights the increased risk associated with advancing age.

Question 54

Which sex is at higher risk of developing melanoma?

Answer 54

Male ## Footnote The risk ratio indicates that males are more likely to develop melanoma compared to females.

Question 55

What skin characteristics are associated with a higher risk of melanoma?

Answer 55

Skin colour, phenotype (ability to tan vs burn), and freckling ## Footnote Individuals with red hair are particularly at higher risk due to the presence of pheomelanin.

Question 56

What is the significance of having more than 100 melanocytic naevi?

Answer 56

Increased melanoma risk ## Footnote Patients with a higher count of melanocytic naevi are at greater risk for developing melanoma.

Question 57

How many atypical naevi are associated with a stronger increase in melanoma risk?

Answer 57

More than 3-5 atypical naevi ## Footnote Atypical or dysplastic naevi are significantly linked to a higher risk of melanoma.

Question 58

What percentage of melanomas arise in pre-existing naevi?

Answer 58

10-50% ## Footnote This statistic indicates the importance of monitoring existing naevi for changes.

Question 59

What is the risk of developing a second melanoma in patients with a history of cutaneous melanoma?

Answer 59

4% ## Footnote The risk is particularly elevated in the first 1-2 years after the initial diagnosis.

Question 60

What is the risk of melanoma in patients with congenital naevus greater than 20cm?

Answer 60

2-30% ## Footnote Congenital naevi of this size carry a significant risk for melanoma development.

Question 61

What is the genetic contribution to melanoma risk?

Answer 61

Accounts for ≤2% of cases ## Footnote Specific genes such as CMM1 and p16 tumor suppressor gene are involved in melanoma risk.

Question 62

What is the role of the CDKN2A gene in melanoma?

Answer 62

It is a cyclin dependent kinase inhibitor ## Footnote Mutations in this gene can lead to a 10x increased risk of melanoma.

Question 63

Name a condition that predisposes individuals to melanoma due to immunosuppression.

Answer 63

HIV/AIDS ## Footnote Immunosuppressed individuals are at higher risk for various skin cancers, including melanoma.

Question 64

What environmental factor is associated with melanoma risk, especially if experienced at a young age?

Answer 64

Sun exposure ## Footnote A history of blistering sunburns, particularly before the age of 18, increases melanoma risk.

Question 65

Fill in the blank: _______ exposure is a known environmental factor contributing to melanoma risk.

Answer 65

Occupational ## Footnote Certain occupational exposures can elevate the risk of developing melanoma.

Question 66

True or False: Ionizing radiation is an environmental factor that can increase melanoma risk.

Answer 66

True ## Footnote Ionizing radiation exposure is a recognized risk factor for melanoma.

Question 67

List the 8 host factors that predispose to development of melanoma

Answer 67

age Sex skin color previous history of melanoma family history melanocytic naevi pre-existing diseases genetics.

Question 68

List the environmental factors that increase the risk of developing melanoma

Answer 68

sun exposure sun beds occupational exposure ionizing radiation.

Question 71

What are the components of clinical assessment of melanoma using ABCDE?

Answer 71

* asymmetry * border irregularity * colour variation * diameter >6mm * elevation

Question 72

What type of melanoma may be missed using ABCDE assessment?

Answer 72

Nodular melanoma and amelanotic melanoma

Question 73

What percentage of melanomas are non pigmented or amelanotic?

Answer 73

5%

Question 74

Which type of melanoma is more likely to lack pigmentation?

Answer 74

Nodular melanomas

Question 75

What are other symptoms of melanomas?

Answer 75

* They may itch * They may ulcerate * They may bleed * They can regress

Question 76

Which digits are most commonly affected by Subungual melanomas?

Answer 76

* Big toe * Thumb

Question 77

Is the foot or the hand more commonly affected by Subungual melanomas?

Answer 77

Foot

Question 78

What is the classical appearance of a Subungual melanoma?

Answer 78

A longitudinal streak of melanin

Question 79

Why does the longitudinal streak of melanin occur in Subungual melanoma?

Answer 79

Due to a pigment-producing focus of melanocytes in the matrix

Question 80

What is Hutchison’s sign?

Answer 80

The pigment extending onto the proximal and/or lateral nail fold

Question 81

What demographics are most commonly affected by Subungual melanomas?

Answer 81

* Black people * Patients aged 40-60 years

Question 82

What percentage of patients will have more than one melanoma?

Answer 82

1-4%

Question 83

In which demographics do multiple melanomas tend to occur?

Answer 83

* Blacks * Patients aged 40-60 years

Question 84

Where do melanomas tend to metastasize to?

Answer 84

* Brain * Lungs * Subcutaneous tissue

Question 85

True or False: Subungual melanomas are more commonly found on the hand than the foot.

Answer 85

False

Question 87

Melanoma arises from malignant transformation of what cell type?

Answer 87

Melanocytes ## Footnote Melanocytes are of neuroectoderm origin, derived from neural crest cells in the epidermis/dermis.

Question 88

What type of naevus may melanoma arise within?

Answer 88

Dysplastic naevus

Question 89

How does UV light cause melanoma?

Answer 89

UV (especially UVB) light has direct mutagenic effects on DNA, decreasing host defenses and promoting reactive oxygen species of melanin that cause DNA damage and suppress apoptosis.

Question 90

What is the worst subtype of UV light for causing melanoma?

Answer 90

UVB

Question 91

What is the most common oncogene mutation associated with melanoma?

Answer 91

BRAF mutation

Question 92

What are the growth and spreading phases of melanoma?

Answer 92

* Radial growth phase * Vertical growth phase * Metastases

Question 93

Loss of what molecule plays a role in tumor progression in melanoma?

Answer 93

E-Cadherin ## Footnote Melanoma cells express N-cadherin instead, allowing adherence to fibroblasts and endothelial cells.

Question 94

Where can melanomas occur in the eye?

Answer 94

Uveal or conjunctival

Question 95

What are the typical histological features of melanoma in situ?

Answer 95

* Increased number of melanocytes * Atypical melanocytes * Melanocytes seen amongst the more superficial layers of the epidermis (buckshotting)

Question 96

List two grading methods for gauging prognosis in melanoma.

Answer 96

* Breslow thickness * Clark’s level

Question 97

Which grading method for melanoma prognosis is more up to date?

Answer 97

Breslow thickness

Question 98

List six prognostic factors included in pathology reporting for melanoma.

Answer 98

* Depth (Breslow thickness and Clark’s level) * Margin * Mitoses (rate per mm³, >5 mitoses per HPF is a high mitosis rate) * Ulceration * LVI * Regression

Question 99

What does Breslow thickness assess?

Answer 99

Depth from the top of the granular layer of the epidermis to the deepest tumor cell.

Question 100

What is the five-year survival for a Breslow thickness melanoma >8mm thick?

Answer 100

40%

Question 101

What is the five-year survival for a Breslow thickness melanoma 4-6mm thick?

Answer 101

60%

Question 102

What is the five-year survival for a Breslow thickness melanoma 2.5-3.99mm thick?

Answer 102

70%

Question 103

What is the five-year survival for a Breslow thickness melanoma 1.5-2.49mm thick?

Answer 103

80%

Question 104

What is the five-year survival for a Breslow thickness melanoma 0.76-1.49mm thick?

Answer 104

95%

Question 105

What is the five-year survival for a Breslow thickness melanoma <0.76mm thick?

Answer 105

98%

Question 106

What is a Clark’s level 1 lesion?

Answer 106

A premalignant lesion or melanoma in situ; all tumor cells are above the basement membrane.

Question 107

What is a Clark’s level 2 lesion?

Answer 107

These melanomas have invasion in the papillary dermis.

Question 108

What is a Clark’s level 3 lesion?

Answer 108

These lesions fill the papillary dermis, with cells at the junction of the papillary and reticular dermis.

Question 109

What is a Clark’s level 4 lesion?

Answer 109

These melanomas invade the reticular dermis.

Question 110

What is a Clark’s level 5 lesion?

Answer 110

Invasion of the melanoma into the subcutaneous fat.

Question 111

Which is more up to date out of Breslow and Clark?

Answer 111

Breslow

Question 112

When does the outdated prognostic tool Clark’s levels still get used?

Answer 112

In tumors ≤1cm, where Clark’s levels still retain their prognostic significance.

Question 114

How should melanoma be examined?

Answer 114

With hand held dermoscopy ## Footnote Dermoscopy enhances visualization of skin lesions to assist in diagnosis.

Question 115

What margins should a suspected melanoma be excised with?

Answer 115

2mm margins ## Footnote Adequate margins help ensure complete removal of the melanoma.

Question 116

Under what circumstances may a punch or incisional biopsy be appropriate?

Answer 116

When suspicion of melanoma is low or for large facial or acral lesions ## Footnote These methods can minimize tissue loss and are suitable for specific situations.

Question 117

How should Subungual melanomas be excised?

Answer 117

A longitudinally oriented incisional biopsy including a nail bed sample and a biopsy of the centre of the lesion ## Footnote Lateral parts may appear more benign, necessitating careful sampling.

Question 118

When should FNA of lymph nodes be done?

Answer 118

For lymph nodes that are suspicious for metastases ## Footnote FNA is preferred to excision biopsy for assessing lymph node involvement.

Question 119

What 4 types of melanoma should be staged?

Answer 119

* Node positive melanomas * Deep melanomas * Recurrent melanomas * Metastatic melanomas ## Footnote Staging is crucial for determining the extent of disease and treatment planning.

Question 120

What investigations are necessary to complete melanoma staging?

Answer 120

* LDH * CXR * +/- CT (head, chest, abdomen, and pelvis) ## Footnote These tests help assess disease spread and organ involvement.

Question 121

When should stages 1 and 2 be fully investigated?

Answer 121

When they have a positive sentinel lymph node biopsy and symptoms suggestive of metastases ## Footnote Routine investigations are not indicated otherwise.

Question 122

When should stage 3 disease be fully staged?

Answer 122

If there is macroscopic disease ## Footnote Staging is important for guiding treatment in advanced cases.

Question 123

What is the incidence of detection on CT or PET for stage 3 disease?

Answer 123

10-20% ## Footnote False positives occur in approximately 10% of these cases.

Question 124

Does staging provide any survival advantage?

Answer 124

No ## Footnote Evidence suggests that staging does not improve overall survival rates.

Question 125

What advantage may staging confer?

Answer 125

May save an unnecessary lymph node dissection for up to 50% of patients with a positive lymph node ## Footnote Staging can help identify patients who may not require extensive surgery.

Question 126

When should LDH be checked?

Answer 126

In patients with greater than or equal to two stage 3 disease only ## Footnote Elevated LDH correlates with poorer outcomes.

Question 127

What is the smallest tumor deposit detectable with USS?

Answer 127

4mm ## Footnote Ultrasound can be used for detecting lymph node involvement.

Question 128

When is CT staging recommended?

Answer 128

If the primary tumor is more than 4mm deep ## Footnote Deeper tumors have a higher risk of metastasis.

Question 129

What else may be useful for staging?

Answer 129

MRI and PET ## Footnote These imaging modalities can provide additional information about metastatic spread.

Question 130

Is PET or Sentinel lymph node biopsy more sensitive for lymph node metastases?

Answer 130

Sentinel lymph node biopsy is more sensitive ## Footnote PET scans may miss small metastases.

Question 132

List methods for preventing melanoma

Answer 132

* Avoid sun * Protective clothing * Sunscreen that blocks UVA and UVB * No sun beds * Statins and fibrates are controversial but may reduce incidence of, slow progression of, and reduce recurrence of melanoma ## Footnote Statins and fibrates are medications that have been discussed in the context of melanoma prevention, though their efficacy is debated.

Question 133

When should melanomas greater than 1mm be considered for referral to a specialized melanoma centre?

Answer 133

To ensure best practice is followed and for the collection of data ## Footnote Referrals are essential for managing higher risk cases effectively.

Question 134

What re-excision margins are necessary for a melanoma that is in situ?

Answer 134

0.5cm ## Footnote In situ melanomas are localized and require less extensive margins.

Question 135

What re-excision margins are necessary for a melanoma that is less than 2mm thick?

Answer 135

1cm ## Footnote This margin is standard for thin melanomas.

Question 136

What re-excision margins are necessary for a melanoma that is 2-4mm thick?

Answer 136

1-2cm ## Footnote This range accommodates for the increased risk of metastasis.

Question 137

What re-excision margins are necessary for a melanoma that is greater than 4mm thick?

Answer 137

2cm ## Footnote Thicker melanomas require wider margins to reduce recurrence risk.

Question 138

When might you add an additional 1cm to your re-excision margin?

Answer 138

When the lesion is desmoplastic or neurotrophic ## Footnote These types of lesions may have more aggressive characteristics.

Question 139

What re-excision options are considered for finger or subungual lesions?

Answer 139

Amputation of digit or amputation at DIP for subungual lesions ## Footnote These options are considered when conservative excision is not sufficient.

Question 140

What are the main principles/excision pointers for re-excising melanoma margins?

Answer 140

Re-excision is full thickness, down to fascia, with no coning in ## Footnote This technique ensures complete removal of the melanoma.

Question 141

What is the rationale for wide excision margins?

Answer 141

Wide excision margins allow excision of occult cutaneous micro metastases, preventing local recurrence ## Footnote This approach aims to minimize the risk of leaving behind malignant cells.

Question 142

What re-excision margin do you aim for in a lesion less than 2mm thick? Why?

Answer 142

1cm, because there is no difference between 1cm margins and 3cm margins ## Footnote This finding supports more conservative surgical approaches for thin lesions.

Question 143

Is there a difference in outcome using a 2cm margin vs a 4cm margin for melanomas 1-4mm thick?

Answer 143

No ## Footnote This indicates that wider margins may not always translate to better outcomes.

Question 144

Is there a difference in outcome using a 2cm margin vs a 5cm margin for melanomas of what thickness?

Answer 144

0.8-2cm (Swedish study) ## Footnote This study suggests that excessively wide margins do not improve survival rates.

Question 145

What did the UK melanoma group show regarding using a 1cm margin over a 3cm margin for lesions greater than or equal to 2mm?

Answer 145

No difference in overall survival, however there was lower local recurrence ## Footnote This supports the use of narrower margins in certain cases.

Question 146

What did a systematic review in 2007 suggest about re-excision margins of 2cm for lesions greater than 2mm?

Answer 146

May reduce local recurrence and increase disease-free survival ## Footnote This highlights the importance of adequate margins in managing thicker melanomas.

Question 147

Where should subungual melanomas be re-excised?

Answer 147

Through the DIP usually ## Footnote This technique is necessary for adequate removal of the lesion.

Question 148

How should eye melanoma be managed?

Answer 148

Referral to ophthalmology, including for consideration of eye-conserving excisions ## Footnote This approach balances the need for treatment with the preservation of vision.

Question 150

How should you manage a positive lymph node (clinical or on imaging)?

Answer 150

Confirm with FNA, stage the patient with CT head/chest/abdo/pelvis, then perform therapeutic lymph node dissection. ## Footnote ANZ guidelines 2008

Question 151

What percentage of patients may benefit from therapeutic lymph node dissection?

Answer 151

13-59% of patients will not develop further metastases. ## Footnote Thompson, Sydney melanoma unit, Lancet 2005; 365:687-701

Question 152

Is there evidence for elective lymph node dissection in the absence of positive nodes?

Answer 152

No evidence for overall survival; may be increased survival in men with 1.5-4mm lesions on trunk or young patients with 1-2mm nonulcerated lesions.

Question 153

What are the complications of therapeutic lymph node dissection?

Answer 153

* Haematoma * Infection * Seroma * Nerve damage * Lymphoedema

Question 154

What percentage of patients will have positive nodes on therapeutic lymph node dissection?

Answer 154

20% of patients.

Question 155

Which nodes are removed in a groin lymph node dissection?

Answer 155

The inguinal lymph nodes plus or minus iliac/pelvic lymph nodes.

Question 156

When should iliac nodes be included in a groin lymph node dissection?

Answer 156

When there are pelvic nodes positive clinically or on imaging, when three or more superficial inguinal nodes are involved, +/- if Cloquet's nodes are involved.

Question 157

What nodes should be dissected in the axilla?

Answer 157

Levels 1-3.

Question 158

For head and neck melanomas, what level cervical dissection should be done for the face?

Answer 158

A level four lymph node dissection.

Question 159

For head and neck melanomas, what level cervical dissection should be done for the mid coronal area?

Answer 159

All lymph nodes (including consideration of parotid nodes).

Question 160

What is Cloquet's node also known as?

Answer 160

Rosenmüller's node.

Question 161

What is Cloquet's node?

Answer 161

A deep inguinal lymph node located at the superior limit of the inguinal region, beneath the inguinal ligament.

Question 162

Does sentinel lymph node biopsy improve overall survival?

Answer 162

The impact of sentinel lymph node biopsy is unclear.

Question 163

When should sentinel lymph node biopsy for melanoma be done?

Answer 163

* Lesions greater than 1mm deep * Clark's level IV+ * Ulcerated * <45 years old * High mitotic rate * Vascular invasion

Question 164

Describe the technique for sentinel lymph node biopsy for melanoma.

Answer 164

Pre-op scintiscan, 2mL Patent Blue dye, wait 5 minutes, excise node; no frozen section.

Question 165

List the complications of sentinel lymph node biopsy in melanoma and their rate.

Answer 165

* Wound infection (0.5-1%) * Seroma/haematoma (3-5%) * Lymphoedema (0.5-5%) * Allergic reaction to dye (1.5-2%)

Question 166

What percentage of melanoma sentinel lymph node biopsies are positive?

Answer 166

Approximately 15%.

Question 167

If the sentinel lymph node is positive, what percentage of patients will have other positive nodes in their therapeutic lymph node dissections?

Answer 167

Approximately 20% of patients.

Question 168

What survival benefit does sentinel lymph node biopsy offer for intermediate thickness melanoma (1.2-3.5mm)?

Answer 168

No survival benefit compared to 'watching & waiting'.

Question 169

What were the key findings of the multi-centre selective lymphadenectomy trial (MSLT-1 2006)?

Answer 169

* Both SLNBx and watch and wait had 16% lymph node metastases * No difference in overall survival * Disease-free survival was 73% in SLNBx patients vs 78% watch and wait * More involved nodes found in the watch and wait group.

Question 170

What did the MSLT-2 trial investigate and find?

Answer 170

No survival benefit from completion LNDx over active surveillance.

Question 171

What are the limitations on the generalizability of the MSLT-2 trial?

Answer 171

* Underrepresentation of head and neck melanomas * High positive SLNBx burden underrepresented * Selection bias due to diagnostic methods.

Question 172

Do micromets affect prognosis?

Answer 172

Micromets may not progress to overt metastases and don’t confer adverse prognosis.

Question 173

What was the rate of lymphoedema in the LNDx group vs the observation group in the MSLT 2 trial?

Answer 173

24% in the LNDx group vs 6% in the observation group.

Question 174

Why are head and neck melanomas more complex to apply the MSLT 2 findings to?

Answer 174

* Underrepresentation in trial * Rarely positive SLNBx * Potential problems with facial nerve due to parotid involvement * Complex lymph node drainage.

Question 175

What should you do if considering SLNBx in head and neck melanoma?

Answer 175

* Do scintiscan first * Refer to specialist centre.

Question 176

What is the best mode of node localisation for SLNBx in pregnancy?

Answer 176

SLNBx with technetium only 'probably safe'; do not use Patent Blue.

Question 178

What are the subgroups of melanoma?

Answer 178

* Superficial spreading * Nodular malignant * Lentigo maligna * Acral lentiginous * Desmoplastic ## Footnote Prevalence percentages: Superficial spreading (50-65%), Nodular malignant (30%), Lentigo maligna (7%), Acral lentiginous (less than 5%), Desmoplastic (amelanocytic)

Question 179

What is the prevalence of superficial spreading melanoma?

Answer 179

50-65% ## Footnote Superficial spreading is the most common subtype of melanoma.

Question 180

What is the prevalence of nodular malignant melanoma?

Answer 180

30% ## Footnote Nodular malignant is the second most common subtype of melanoma.

Question 181

What is the prevalence of lentigo maligna melanoma?

Answer 181

7% ## Footnote Lentigo maligna is less common than the first two subtypes.

Question 182

What is the prevalence of acral lentiginous melanoma?

Answer 182

Less than 5% ## Footnote Acral lentiginous melanoma is one of the rare subtypes.

Question 183

What is the prevalence of desmoplastic melanoma?

Answer 183

Amelanocytic ## Footnote Desmoplastic melanoma is characterized by a lack of pigment.

Question 184

What is the Glasgow seven point checklist for melanoma?

Answer 184

A score to determine if a lesion should be biopsied or referred ## Footnote A score greater than 2 points indicates a need for a biopsy or referral.

Question 185

What are the major features of the Glasgow seven point checklist for melanoma?

Answer 185

* Change in size (+2 points) * Irregular shape (+2 points) * Irregular colour (+2 points) ## Footnote Major features contribute significantly to the total score.

Question 186

What are the minor features of the Glasgow seven point checklist for melanoma?

Answer 186

* Diameter >7mm (+1 point) * Inflammation (+1 point) * Oozing (+1 point) * Change in sensation (+1 point) ## Footnote Minor features add to the total score but are less significant than major features.

Question 187

Fill in the blank: If a lesion scores more than ___ points on the Glasgow seven point checklist, it should be biopsied or referred.

Answer 187

2 ## Footnote This scoring system helps in early detection of melanoma.

Question 189

What are the benign lesions included in the differential diagnosis for a pigmented lesion?

Answer 189

Freckle, Lentigo, naevus (melanocytic, dysplastic) ## Footnote Benign lesions are typically non-cancerous and may include various skin markings.

Question 190

What are the malignant lesions included in the differential diagnosis for a pigmented lesion?

Answer 190

Melanoma, pigmented SCC, BCC ## Footnote Malignant lesions indicate the presence of cancer and may require immediate medical attention.

Question 191

What is included in the differential diagnosis for a non-pigmented lesion?

Answer 191

SCC, BCC, melanotic melanoma, Market cell tumour ## Footnote Non-pigmented lesions can also be indicative of malignancies and should be evaluated carefully.

Question 192

Fill in the blank: Benign lesions in the differential diagnosis for a pigmented lesion include freckle, Lentigo, and _______.

Answer 192

naevus (melanocytic, dysplastic) ## Footnote Naevus refers to a common type of skin mole.

Question 193

True or False: Melanoma is considered a benign lesion.

Answer 193

False ## Footnote Melanoma is a type of skin cancer and is classified as a malignant lesion.

Question 194

Fill in the blank: Non-pigmented lesions may include SCC, BCC, and _______.

Answer 194

melanotic melanoma ## Footnote Melanotic melanoma is a type of melanoma that may appear non-pigmented in some cases.

Question 196

What is the depth, risk of lymph node metastases, and 5 year survival of a thin breslow thickness lesion?

Answer 196

<1mm, <5%, >95% ## Footnote Thin breslow thickness lesions have a very low risk of lymph node metastases and a high 5-year survival rate.

Question 197

What is the depth, risk of lymph node metastases, and 5 year survival of an intermediate breslow thickness lesion?

Answer 197

1-4mm, 10-30%, 70-80% ## Footnote Intermediate breslow thickness lesions have a moderate risk of lymph node metastases and a reasonable 5-year survival rate.

Question 198

What is the depth, risk of lymph node metastases, and 5 year survival of a thick breslow thickness lesion?

Answer 198

>4mm, >40%, 50% ## Footnote Thick breslow thickness lesions have a high risk of lymph node metastases and a significantly lower 5-year survival rate.

Question 199

Clarks levels are outdated, but important in which melanomas?

Answer 199

Thin melanomas <1mm

Question 200

A Clark’s level one lesion invades what? How else might this be described?

Answer 200

Confined to the epidermis, this is a premalignant lesion or melanoma in situ

Question 201

Where does a Clark’s level 2 lesion invade to?

Answer 201

Into the papillary dermis

Question 202

Where does a Clark’s level 3 lesion invade to?

Answer 202

Fills the papillary dermis

Question 203

Where does a Clark’s level 4 lesion invade to?

Answer 203

Invades the reticular dermis

Question 204

Where does a Clark’s level 5 lesion invade to?

Answer 204

Invades into the subcutaneous tissue

Question 205

What kind of biopsy should you take of small lesions suspicious for melanoma? Why?

Answer 205

An excisional biopsy with 2mm margins, so as not to disrupt the lymphatics for later SLN Bex

Question 206

When and how should lymph nodes be sampled in melanoma?

Answer 206

FNA for lymph nodes that are clinically suspicious

Question 207

When should staging imaging be done? What modes of imaging should be used?

Answer 207

Recommended only for advanced disease - with known or suspected Mets. CT brain +/- MRI brain Plus CT PET or CT CAP

Question 208

What are the key factors in melanoma T staging? What is T staging important for?

Answer 208

T staging is vitally important for prognosis and assessing the need for further investigation and treatment. Key factors are 1. Breslow thickness - 4mm = T4 2. Sub category for ulceration a/b

Question 209

What does N staging for melanoma take into account?

Answer 209

N stage notes if there are micro or macro metastases, ad if there is in transit disease

Question 210

What are the T stages for Stage 1 melanoma?

Answer 210

Early localized - T1, T2a

Question 211

What are the T stages for stage 2 melanoma?

Answer 211

Advanced localized 0 T2b, T3, T4

Question 212

What is the defining feature of stage 3 melanoma?

Answer 212

Stage 3 melanoma means that lymph nodes are involved. There is a big difference in survival between 3a and 3d. Stage 3 takes into account lymph nodes, in transit Mets, and satellite mets

Question 213

What is the defining feature of stage 3 melanoma?

Answer 213

Stage 3 melanoma means that lymph nodes are involved. There is a big difference in survival between 3a and 3d. Stage 3 takes into account lymph nodes, in transit Mets, and satellite Mets

Question 214

What is the defining feature of stage 4 melanoma?

Answer 214

Distant metastases

Question 215

What does the T stage in melanoma take into account?

Answer 215

Lesion depth and presence or absence of ulceration.

Question 216

How deep is a Tis and a T1 lesion?

Answer 216

Tis - remains in epidermis T1 - <1mm. T1 a<0.8mm T1b >0.8mm

Question 217

How deep is a T2, T3, and T4 melanoma lesion?

Answer 217

T2 1-2mm T3 2-4mm T4 - >4mm

Question 218

How many lymph nodes are involved in an N0 lesion? What about in an N1a and N1b lesion?

Answer 218

N0 no lymph nodes N1a 1 lymph node with micromets N1b 1 lymph nodes with macromets

Question 219

How many lymph nodes are involved in an N2 lesion? How about an N3 lesion? How can this be refined?

Answer 219

N2 0 2-3 lymph nodes (a micromets, b macromets) N3 4 LNs (a micromets, b macromets, c in transit or satellite + leaving now met)

Question 220

How many lymph nodes are involved in an N2 lesion and an N3 lesion? How might this be refined?

Answer 220

N2 0 2-3 lymph nodes (a micromets, b macromets) N3 4 LNs (a micromets, b macromets, c in transit or satellite + leaving now met)

Question 221

What is in-transit disease? What is a satellite lesion?

Answer 221

In transit - is in the lymphatics along the path leading to draining lymph nodes, >2cm away from the primary Satellite lesions - in the skin <2cm away from the primary lesion

Question 222

What is an M0 stage of melanoma

Answer 222

No distant metastases

Question 223

What is an M1 a, M1b, Mac, and M1d stage in melanoma?

Answer 223

M1a - skin/soft tissue met M1b - lung met M1c - other e.g. visceral or increased LDH M1d - brain met

Question 224

How do you determine WLE margins for a melanoma lesion? List the margins for Tis-T4 disease. When should lesions be wider than this?

Answer 224

Margins depend on depth. Tis 0.5cm T1 1cm T2 1-2cm T3, T4 2cm Margins should be an extra centimeter wider for desmoplastic/neurotrophic lesions

Question 225

What are the WLE margins for a Subungual lesion?

Answer 225

Amputate at the DIP

Question 226

What is the technique for a WLE for melanoma?

Answer 226

Full thickness excision down to deep fascia with no coning in. May require flap or graft.

Question 227

What are the advantages of a partial thickness graft over full thickness? And vice versa?

Answer 227

Partial thickness - better survival, easier to stretch, can harvest a larger donor site Full thickness - better cosmetics, less likely to contract, better for face.

Question 228

What ratio of tissue needs to be mobilized for a flap on the scalp? On the body?

Answer 228

6:1 on the scalp ie mobilise 6cm to cover 1cm 3:1 on the body.

Question 229

Into what two groups should patients be placed when considering who needs a SLNB or therapeutic dissection?

Answer 229

Clinically node negative patients (no clinical or radiological lymphadenopathy Clinically node positive patients

Question 230

When should SLNBx be done in a clinically node negative patient? How might this be calculated?

Answer 230

Any patient with a <5% risk of positive nodes doesn’t need SLNBx. This is generally lesions <1mm thick without adverse features. This risk can be calculated with an online validated prediction tool e.g. MSK melanoma nomogram

Question 231

When does a clinically node negative patient need SLNBx?

Answer 231

Any patient with a <5% risk of positive nodes doesn’t need SLNBx. This is generally lesions <1mm thick without adverse features. This risk can be calculated with an online validated prediction tool e.g. MSK melanoma no Morgan

Question 232

What is the MSK melanoma SLNBx nomogram useful for?

Answer 232

Determining risk of detecting positive lymph nodes, and therefore determining whether a SLNBx is indicated.

Question 233

What are four points that highlight the rationale for sentinel lymph node biopsy in melanoma?

Answer 233

1. Accurate pathological staging 2. Better loco-regional disease control 3. Improved disease free survival 4. Identifies patients for adjuvant systemic therapy

Question 234

What are the two categories of patients that should receive SLNBx in melanoma?

Answer 234

1. If no clinically palpable LNs and T2 and above ie >1mm thick OR 2. Breslow 0.8mm-1mm with high risk features e.g. ulceration or high mitosis rate ie include some T1b tumors.

Question 235

What is the technique for lymphatic mapping and biopsy?

Answer 235

1. Lymphoscintigraphy with technetium 99 labeled sulphuric colloid injected intradermally in 4 quadrants around the scar 3-24hrs prior to operation 2. Patient blue die injected intradermally in 4 quadrants immediately prior to operation Any blue or hot lesions (use gamma probe) are excised

Question 236

How should lymph nodes be localized in pregnancy?

Answer 236

Dont use patent blue, only lymphoscintigraphy

Question 237

What is the sensitivity of dual localisation of lymph nodes in melanoma? How is this known?

Answer 237

99%. In the MSLT1 trial the observation arm and lymphadenectomy arm had roughly the same number of nodes involved once disease became apparent in observation arm. The suggestion is that those Mets were likely already present at diagnosis and SNB is accurate at staging.

Question 239

What are the risks of sentinel lymph node biopsy? (List 5)

Answer 239

Infection Bleeding Injury to local structures CN7, CN11, Vagus?? (<1%) Lymphoedema (leg>axilla>neck) <1% - way less than ALND Anaphylaxis to patent blue

Question 240

How should a negative SLNBx patient be managed?

Answer 240

Better overall prognosis than those even with micromets Do routine surveillance

Question 241

How should a patient with positive SLNBx be managed?

Answer 241

1. Complete staging with imaging as this may change management 2. If no distant Mets then intensive surveillance and LND only if clinical regional recurrence.

Question 242

What was the MST II trial result for management of positive SLNBx patients - observation vs immediate nodal dissection?

Answer 242

Observe, not immediate nodal dissection Because no overall survival benefit On balance this improved local disease control vs nodal dissection morbidity+++ 80% of the +ve SLNBx group didn’t develop local recurrence, so the SLNBx removed most of the disease

Question 243

Describe what is involved in “intensive surveillance” of a patient with a positive SLNBx result

Answer 243

3 monthly for 2 years, 6 monthly for 5 years, annual thereafter Therapeutic LND if patient develops positive lymph nodes during surveillance

Question 244

When was recruitment and what were the groups in the MSLT 1 trial? What were the 4 main conclusions of the trial?

Answer 244

Recruitment 1994-2004 Observational group - if nodal ultrasound was eventually positive then patient received delayed lymphadenectomy SLNBx group - if positive SLNBx a completion LNDx was done 1. +ve SLNBx was poor prognostic factor 2. Pts with leaving now Mets and intermediate thickness melanoma (1.2-3.5mm) - 10 year melanoma specific survival was far worse in the observational group (41.5%) than the SLNBx group (62.1%) 3. There was no difference in survival between groups in thick melanoma >3.5mm 4. Conclusion: biopsy based staging of intermediate thickness or thick primary melanomas provides important prognostic information and identifies patients who may benefit from completion lymphadenectomy. It prolongs DFS and distant disease free survival and melanoma specific survival for patients with nodal metastases from intermediate thickness melanomas

Question 245

When was recruitment for the MSLT II trial What were the observation and trial groups? What were the main conclusions?

Answer 245

2004-2014 SLNBx +ve randomized to completion lymphadenectomy vs observation with nodal USS +/- delayed lymphadenectomy Conclusion: Immediate completion LND increased the rate of regional disease control and provided prognostic information but did not increase melanoma specific survival among patients with melanoma and SLN metastases. The lymphoedema rate was 40% in the dissection group.

Question 246

How should clinically node positive patients be managed?

Answer 246

If palpable, FNA. If FNA negative , consider excisional biopsy

Question 247

If FNA of a clinically positive node is positive, what is the minimum disease stage? What is the next step in management of this patient?

Answer 247

Minimum stage 3 disease Imaging CT brain and PET CT as this may influence management

Question 248

If a patient has a positive lymph node on FNA and no Mets on imaging, what is the next step?

Answer 248

Therapeutic lymph node dissection

Question 249

What are the appropriate lymph node basins/dissections for the axialla, groin and neck?

Answer 249

Axilla - level III+ resect pec minor Groin - sub inguinal (include femoral triangle, cloquets node, +/- ilia inguinal if pelvic leaving now - Obturator and int/ext iliac Neck - modified radial neck dissection (levels 2-5) + superficial paratidectomy

Question 250

What are the appropriate lymph node basins for axilla, groin, and neck dissections in patients with a positive SLNBx and no Mets?

Answer 250

Axilla - level III+ resect pec minor Groin - sub inguinal (include femoral triangle, cloquets node, +/- ilia inguinal if pelvic leaving now - Obturator and int/ext iliac Neck - modified radial neck dissection (levels 2-5) + superficial paraglide to my

Question 251

How do you manage a patient with a positive lymph node but no primary?

Answer 251

1. Examine carefully 2. CT PET. If negative, assume primary has complete regressed 3. Treat the leaving now Mets with LNDx if no Mets - this has survival benefit.

Question 252

Which melanoma patients should be discussed at a melanoma MDM, considered for adjuvant radiotherapy and or systemic treatment and or enrollment in clinical trials, considered for neoadjuvant therapy?

Answer 252

Patients with respected stage 3 and 4 or stage 2b and 2c melanoma NB neoadjvant therapies are not yet funded in NZ

Question 253

What are the indications for radiotherapy in melanoma? Primary site? Lymph nodes? Stage IV disease? What is the impact of radiotherapy?

Answer 253

Primary site - inoperable disease, involved or close margins with not able to do further excision, poor prognostic factors e.g. high risk for recurrence, breslow >4mm, ulceration, satelitosis, LVI LNs - RX to regional nodes basin after LNDx if large volume or matted disease - e.g. >1 parotid, >2 axillary, > 3 inguinal, or size >3cm axillary or cervical or 4cm inguinal. Extracapular extension, regional recurrence (after re excision) Stage IV disease - palliative role in symptomatic brain and bone Mets. Radiotherapy reduces local recurrence but does not impact overall survival.

Question 254

What investigations are indicated in known metastatic melanoma?

Answer 254

1. PET CT to look for occult metastases 2. MRI brain 3. Serum LDH (important prognostic implications) 4. Assess for mutation at V600 site in BRAF

Question 255

What are the 4 treatment options for metastatic melanoma?

Answer 255

RAPTOR Surgical metastectomy (up to 3) Immunotherapy - IL2, ipilimumab, PD1 Targeted inhibition of MAP kinase pathway - BRAF inhibitor V600 Dabrafenib, veurafenib, - MEK inhibitor Trametinib Radiotherapy to symptomatic sites CHEMOTHERAPY NO ROLE

Question 256

List three immunotherapies for melanoma What other pathways can be targeted

Answer 256

IL-2, ipilimumab, PD1 MAP kinase pathway inhibition

Question 257

List two subtypes of MAP kinase inhibition

Answer 257

BRAF inhibition (V600) Dabrafenib and beurafenib MEK inhibitor - trametinib

Question 258

How do you manage locoregional recurrence /incomplete margins? How do you manage in transit Mets and satelitiosis?

Answer 258

Re excise if suitable Consider adjuvant radiotherapy if pt unfit or anatomical constraint For in transit Mets and satelitosis - local management - metastatic to my, diphencyprine, imiquimod, isolated limb infusion ,PB 10 injection, radiotherapy, amputation For systemic treatment - ILd, BRAF inhibitor.

Question 259

Give the 5 year survival for stages 1-4 melanoma

Answer 259

1 90% 2 70% 3 45% 4 10%

Question 260

How may poor prognostic factors in melanoma be classed? Give all prognostic factors under these classes

Answer 260

Patient factors and other - age - male gender Primary tumor - breslow thickness and Clark’s level in thin tumors - ulceration - mitotic rate - site - head and neck worse than trunk and limbs Nodes (and in transit disease and satellite lesions) - SLN involvement - number oof LNs involved - micro vs macromets Metastases - number of sites -Visceral - respectability - serum LDH - poor performance status

Question 261

What are the three predictors of survival in melanoma?

Answer 261

Tumor - breslow, ulceration, mitotic rate Nodes - number, tumor burden (macro micro), matted Metastases - visceral

Question 262

How should melanoma be followed up per stage? What else should be recommended? What do you check at follow up?

Answer 262

Stage 1 6 monthly for 5 years then yearly thereafter Stage 2, 3,4 - 3 monthly for 2 years, 6 monthly til 5 years, annual thereafter Other - encourage first degree relatives to be examined for atypical lesions and give sun protection advice Encourage regular self examination Check for local recurrence, satellite lesions, and the rest of the skin for new melanoma, and lymph nodes.

Question 263

How should you manage Lentigo maligna (cf Lentigo maligna melanoma)

Answer 263

This is a type of melanoma in situ 50% become invasive Biopsy. If Lentigo maligna excise with a 5mm margin. Confocal microscopy can help to determine margin Use radiotherapy Aldara/imiquimod - this modifies the immune response. Topical application

Question 264

How does imiquimod work?

Answer 264

It activates langerhans cells which migrate to local lymph nodes to activate the adaptive immune system.