Tag: Malignant Melanoma

Malignant Melanoma

MALIGNANT MELANOMA


MALIGNANT MELANOMA (MELANOCARCINOMA)

  • Malignant melanoma is a malignant tumour arising from epidermal melanocyte derived from neural crest.
  • Most aggressive cutaneous malignant tumour.
  • DOPA REACTION-

SITES FOR MALIGNANT MELANOMA-

  • Head & neck
  • Lower extremity
  • Trunk
  • Upper limb
  • Choroid of the eye
  • Genetalia
  • MC site for men- front or back of the trunk
  • MC site for female- leg
  • More common in whites than black

 ETIOLOGY-

  • UV rays
  • Albinism
  • Xeroderma pigmentosa- AR (Chromosome 9q)
  • Genetic factors-

i) Tumour suppressor gene mutation 9q 21

ii) Deletion or rearrangement of chromosome 10 & 8p

iii) Dysplastic naevus syndrome

  • Pre- existing mole
  • Immunocompromised- HIV, Hodgkin’s disease

CLASSIFICATION-

I) Breslow classification-

  • According to maximum thickness at the centre of the lesion-

a) Stage I- thickness less than 0. 75 mm

b) Stage II- 0.75 mm to 1.5 mm

c) Stage III- 1.5 mm to 3.0 mm

d) Stage IV- more than 3 mm

II) Clark’s Classification-

  • According to the basis of the depth of the invasion

a) Stage I- Melanoma restricting to epidermis and appendages

b) Stage II- invading papillary dermis without filling it

c) Stage III- reach interface of papillary and reticular dermis

d) Stage IV- invading reticular dermis

e) Stage V- invading subcutaneous tissue

III) According to clinical types-

a) Lentigo malignant melanoma-

  • Benign
  • MC- face

b) Superficial spreading-

  • MC type
  • MC site- torso

c) Nodular-

  • Most malignant
  • MC site- head, neck, trunk

d) Acral lentiginous-

  • Least common with worst prognosis
  • MC site- sole, mucosa

CLINICAL FEATURES-

  • Can spread from mother to foetus
  • Asymmetry, border irregularity, color variation and diameter >6mm (ABCD)
  • Microsatellites (0.05mm)- separated from main body tumour by normal dermal collagen or subcutaneous fat
  • Macrosatellites associated with increase risk of regional LN
  • MC site of systemic metastasis- liver
  • Choroidal melanoma is the most common primary malignant intraocular tumor and the second most common type of primary malignant melanoma in the body and may produce  exudative retinal detachment.
  • In melanoma cells, numbers of mutations and/or dysregulated expression of B-Rof N-Ras, CDK2A, MDM2, PTEN, p53 have been recognized”

SPREAD-

  • Through lymphatics (MC)
  • In- transit or satellite nodules
  • Through blood 

INVESTIGATIONS-

  • Chest X-ray- cannonball secondaries
  • USG abdomen- secondary in liver
  • FNAC- detects spreading & stages of the disease
  • Serum LDH levels- indicate metastatic disease
  • HHB- 4S- premelanosomal protein is specific immunohistochemical marker for melanoma
  • Full thickness excisional biopsy- confirms MM

TREATMENT-

  • Surgical excision with sentinel LN biopsy
  • Block dissection to be done when sentinel node is involved

Exam Important

According to clinical types-

a) Lentigo malignant melanoma-

  • Benign
  • MC- face

b) Superficial spreading-

  • MC type
  • MC site- torso

c) Nodular-

  • Most malignant
  • MC site- head, neck, trunk

d) Acral lentiginous-

  • Least common with worst prognosis
  • MC site- sole

CLINICAL FEATURES-

  • Can spread from mother to foetus
  • Asymmetry, border irregularity, color variation and diameter >6mm (ABCD)
  • Microsatellites (0.05mm)- separated from main body tumour by normal dermal collagen or subcutaneous fat
  • Macrosatellites associated with increase risk of regional LN
  • MC site of systemic metastasis- liver
  • Choroidal melanoma is the most common primary malignant intraocular tumor and the second most common type of primary malignant melanoma in the body and may produce  exudative retinal detachment.
  • In melanoma cells, numbers of mutations and/or dysregulated expression of B-Rof N-Ras, CDK2A, MDM2, PTEN, p53 have been recognized”

SPREAD-

  • Through lymphatics (MC)
  • In- transit or satellite nodules
  • Through blood

INVESTIGATIONS-

  • Chest X-ray- cannonball secondaries
  • USG abdomen- secondary in liver
  • FNAC- detects spreading & stages of the disease
  • Serum LDH levels- indicate metastatic disease
  • HHB- 4S- premelanosomal protein is specific immunohistochemical marker for melanoma
  • Full thickness excisional biopsy- confirms MM

TREATMENT-

  • Surgical excision with sentinel LN biopsy
  • Block dissection to be done when sentinel node is involved
Don’t Forget to Solve all the previous Year Question asked on MALIGNANT MELANOMA

Module Below Start Quiz

Malignant Melanoma

Malignant melanoma

Q. 1 Skin biopsy of a patient shows evidence of malignant melanoma. Which is the common type of malignant melanoma?

 A

Superficial spreading

 B

Lentigo maligna melanoma

 C

Nodular

 D

Acral lentiginous

Q. 1

Skin biopsy of a patient shows evidence of malignant melanoma. Which is the common type of malignant melanoma?

 A

Superficial spreading

 B

Lentigo maligna melanoma

 C

Nodular

 D

Acral lentiginous

Ans. A

Explanation:

Superficial spreading melanoma comprises approximately 60% to 70% of melanomas and represents the most common melanoma subtype.
They often arise in a preexisting nevus and typically develop as a spreading pigmented plaque with irregular borders and variation in color and surface contour.
They often exhibit the classic clinical features of melanoma.
Areas of regression may result in pink to white areas within the black or brown tumor.
They may progress to a vertical growth phase faster than lentigo maligna.

 
Ref: Ludgate M.W., Wang T.S. (2009). Chapter 100. Skin Cancer. In J.B. Halter, J.G. Ouslander, M.E. Tinetti, S. Studenski, K.P. High, S. Asthana (Eds), Hazzard’s Geriatric Medicine and Gerontology, 6e.

 


Q. 2

Marker of malignant melanoma is?

 A

HMB 45               

 B

S-100

 C

Synaptophysin

 D

Both A and B

Q. 2

Marker of malignant melanoma is?

 A

HMB 45               

 B

S-100

 C

Synaptophysin

 D

Both A and B

Ans. D

Explanation:

Ans. is ‘a’ i.e., HMB 45 & ‘b’ i.e., S-100


Q. 3

Marker for malignant melanoma is –

 A

Cytokeratin

 B

MBN- 45

 C

Alpha FP

 D

S 100

Q. 3

Marker for malignant melanoma is –

 A

Cytokeratin

 B

MBN- 45

 C

Alpha FP

 D

S 100

Ans. D

Explanation:

Ans. is ‘d i.e., S-100

Tumor markers for malignant melanoma —4 S – 100, TA – 90.

These two markers can be used to look for the spread of melanoma.

Quiz In Between


Q. 4 Most common malignant melanoma is

 A

Superficial spreading

 B

Lentigo maligna melanoma

 C

Nodular

 D

Acral lentiginous

Q. 4

Most common malignant melanoma is

 A

Superficial spreading

 B

Lentigo maligna melanoma

 C

Nodular

 D

Acral lentiginous

Ans. A

Explanation:

Ans. is ‘a’ i.e. Superficial spreading type 

  • There are 4 common type of melanoma (these are in order of decreasing frequency)

a)      Superficial spreading type (most common)

b)         Nodular

c)         Lentigo maligna

d)         Acral lentiginous (least common)

  • Also remember:
  • MC type in dark skinned people —> Acral lentiginous type

Q. 5 The most malignant form of malignant melanoma is ‑

 A

Nodular

 B

Hutchinson’s melanotic freckle

 C

Acral lentiginous type

 D

Superficial spreading

Q. 5

The most malignant form of malignant melanoma is ‑

 A

Nodular

 B

Hutchinson’s melanotic freckle

 C

Acral lentiginous type

 D

Superficial spreading

Ans. A

Explanation:

Ans. is ‘a’ i.e. Nodular

Schwartz 9/e p415 writes that- “In general, there is no significant difference between different histologic tumor types in terms of prognosis, when matched for tumor thickness, gender, age, or other. Nodular melanomas have the same prognosis as superficial spreading types when lesions are matched for depth of invasion. Lentigo maligna types, however, have a better prognosis even after correcting for thickness, and acral lentiginous lesions have a worse prognosis.”


Q. 6 All of the following statements about malignant melanoma are true except:

 A

prognosis is better in female than in male

 B

Acral lentiginous melanoma carries a good prognosis

 C

Stage II A shows satelite deposits

 D

A and b

Q. 6

All of the following statements about malignant melanoma are true except:

 A

prognosis is better in female than in male

 B

Acral lentiginous melanoma carries a good prognosis

 C

Stage II A shows satelite deposits

 D

A and b

Ans. D

Explanation:

Ans. is ‘b’ i.e. acral lentiginous melanoma carries a good prognosis & ‘c’ i.e. stage II A shows satellite deposits

Acral lentignous melanoma has the worst prognosis

  • Satellite deposits are foci of tumor adajent but separate from the primary melanoma also k/a in-transit metastasis. In the original staging system, satellite deposits or lesions were classified as stage II ds.

Conventional staging of melanoma

  • Stage I Primary tumor
  • Stage II Presence of satellites or regional lymph nodes
  • Stage III –> Spread beyond regional lymph nodes
  • But according to latest AJCC classification (2002) presence of satellite lesions is classified as stage III.

More facts about melanoma

  • Most of the melanomas develop in benign nevus.
  • ABCD of melanoma – Lesions that are suspicions of melanoma can be identified by their clinical characteristic often referred to as ABCD.
  • Some books also have an ‘E’. E stands for ‘evolution of lesion’ or ‘elevation’.
  • The treatment is primary surgical
  • Diagnosis is confirmed by biopsy

Quiz In Between


Q. 7 True about malignant melanoma:

 A

Lymphatic spread

 B

Lymph node biopsy is done always

 C

Block dissection to be done when sentinel node is involved

 D

All

Q. 7

True about malignant melanoma:

 A

Lymphatic spread

 B

Lymph node biopsy is done always

 C

Block dissection to be done when sentinel node is involved

 D

All

Ans. D

Explanation:

Ans. is all 

Management of Malignant Melanoma

  • Wide local excision of the primary tumor is the management of choice. The recommended margin of resection depends on the thickness of the tumor.

Recommended Margins for Surgical Resection of Primary Melanoma

Tumor thickness

Margin Radius

< 1.0 mm

1.0 cm

 

1-4 mm

2.0 cm

 

>4 mm

3.0 cm

(Schwartz)

 Sabiston (18/e p773) and Harrison (I7/e p547) differ somewhat from Schwartz. According to Sabiston‑

Recommended Margins for Surgical Resection of Primary Melanoma

Tumor thickness

Margin Radius

In situ

0.5 cm

 

< 1.0 mm

1.0 cm

 

1-2 mm

1.0 – 2.0 cm

 

> 2.0 mm

> 2.0 cm

(Sabiston)

 According to Harrison —

Recommended Margins for Surgical Resection of Primary Melanom:

Tumor thickness

Margin Radius

 

In situ

0.5 cm

 

< 1.0 mm

1.0 cm

 

> 1.0 mm

2.0 cm

(Harrison)

 

  • Sentinel lymph node biopsy is done for tumors more than 1 mm thick. If biopsy is positive complete lymph node dissection is done.

Also know

Treatment of subungual melanoma — amputation of the distal digit to provide a 1 cm margin from the tumor. For fingers, amputation commonly involves only the distal phalanx; ray amputation is not required. (Sabiston 18/e p775) About option ‘d’ i.e. Microsatellitism

[Ref: http://www.moffitt.org/CCIRoot/v12n4/pdf/223.pdf http://www.pubmedcentranih.gov/articlerenderfcgi?artid=1250595 Ann Surg. 1984 December; 200(6): 759-763. http://archderm.ama-assn.org/cgi/reprint/141/6/739.pdf%5D

  • Microsatellites are discrete tumor nests greater than 0.05 mm in diameter that are separated from the main body of the tumor by normal reticular dermal collagen or subcutaneous fat.
  • Microsatellites constitute a risk factor for local recurrence. Melanomas with microsatellites are associated with a greater frequency of local clinical metastasis than those without.
  • Microsatellites are different from Satellite lesions. Satellite lesions are macroscopic finding whereas microsatellites are histopathological findings. Satellite lesions are foci of tumor adajacent to but separate from the primary melanoma. They are also called in-transit metastases, implying that secondary melanomas have grown in the skin on their way to spreading to local lymph nodes.

Q. 8

All are true statement about malignant melanoma except –

 A Clark’s classification used for prognosis

 B

Women have better prognosis

 C

Acral lentigenous have better prognosis

 D

Limb perfusion is used for local treatment

Q. 8

All are true statement about malignant melanoma except –

 A

Clark’s classification used for prognosis

 B

Women have better prognosis

 C

Acral lentigenous have better prognosis

 D

Limb perfusion is used for local treatment

Ans. C

Explanation:

Ans. is ‘c’ i.e., Acral lentigenous have better prognosis 


Q. 9

Prognosis of malignant melanoma depends on

 A

Grade of tumor

 B

Spread of tumor

 C

Depth of invasion

 D

Metastasis

Q. 9

Prognosis of malignant melanoma depends on

 A

Grade of tumor

 B

Spread of tumor

 C

Depth of invasion

 D

Metastasis

Ans. C

Explanation:

Ans. is ‘c’ i.e., Depth of invasion 

Quiz In Between


Q. 10

Least malignant melanoma is

 A

 Lentigo malignant melanoma

 B

Superifcial spreading

 C

Nodular

 D

Amelanotic

Q. 10

Least malignant melanoma is

 A

 Lentigo malignant melanoma

 B

Superifcial spreading

 C

Nodular

 D

Amelanotic

Ans. A

Explanation:

Ans. is ‘a’ i.e., Lentigo maligna 


Q. 11

Malignant melanoma of the choroid will produce:
September 2012

 A

Retinal dialysis

 B

Exudative retinal detachment

 C

Traction retinal detachment

 D

Rhegmatogenous retinal detachment

Q. 11

Malignant melanoma of the choroid will produce:
September 2012

 A

Retinal dialysis

 B

Exudative retinal detachment

 C

Traction retinal detachment

 D

Rhegmatogenous retinal detachment

Ans. B

Explanation:

Ans. B i.e. Exudative retinal detachment


Q. 12

Prognosis of malignant melanoma depends upon:
March 2011, March 2013

 A

Grade of tumour

 B

Age of the patient

 C

Invasion of nearby nodes

 D

Site of lesion

Q. 12

Prognosis of malignant melanoma depends upon:
March 2011, March 2013

 A

Grade of tumour

 B

Age of the patient

 C

Invasion of nearby nodes

 D

Site of lesion

Ans. C

Explanation:

Ans. C: Invasion of nearby nodes

The presence of lymph node metastases is the single most important prognostic index in melanoma, outweighing both tumour and host factors

Melanoma:

  • May be familial
  • Originate from melanocytes
  • Cutaneous melanoma arises from epidermal melanocytes
  • Spread by the lymphatic channels or the bloodstream
  • Lentigo maligna (least common) involves face commonly
  • Superficial spreading is the MC type
  • Nodular melanoma is the most malignant type

Quiz In Between


Q. 13

Most common site of distant metastasis inintraorbital malignant melanoma is‑

 A Brain

 B

Lung

 C

Liver

 D

Lymph nodes

Q. 13

Most common site of distant metastasis inintraorbital malignant melanoma is‑

 A

Brain

 B

Lung

 C

Liver

 D

Lymph nodes

Ans. C

Explanation:

Ans. is `c i.e., Liver

  • Malignant melanoma mostly arise in uvea and uveal malignant melanoma is the most common primary intraocular tumor.
  • The most common site for distant metastasis of uveal melanoma is liver.
  • The liver is the most common site of metastasis of uveal melanoma”                   — Clinical oncology
  • The liver is the most common site of metastatis from primary ocular melanoma”   — Smith & Nesi’s

Uveal melanoma

  • Uveal melanoma is the most common primary intraocular tumor in adults.
  • Most of the (85%) uveal melanomas arise in the choroid.
  • So, choroidal melanoma is the most common primary intraocular tumor in adults.
  • Tumor arises from dendritic melanocytes (neural crest, neuroectodermal origin).
  • Histologically choroidal melanoma can be divided into: –

Spindle cell melanomas : – These melanomas contain predominantly spindle cells.

  • These melanomas are further subdivided into Spindle A or Spindle B depending upon the type of cells.

Epitheloid cell melanomas : – Contain epitheloid like cells.

Mixed cell melanomas : – Contain both spindle cells and epitheloid cells.

  • Choroidal melanoma presents as a sessile or dome shaped mass located deep to the sensory retina.
  • A secondary non-rheugmatogenous retinal detachment frequently occurs.

Involvement of vortex vein by tumor results in glaucoma.

  • With continued growth, a choroidal melanoma can rupture Bruch’s membane and assume a mushroom shape.
  •  When that occurs, tumor has a tendency to bleed, and vitreal or subretinal hemorrhage may occur.

Q. 14 Risk factor for malignant melanoma all the following are risk factors fore malignant melanoma except

 A

Giant congenital nevi

 B

Family history melanoma

 C

Exposure to UV light

 D

HPV infection

Q. 14

Risk factor for malignant melanoma all the following are risk factors fore malignant melanoma except

 A

Giant congenital nevi

 B

Family history melanoma

 C

Exposure to UV light

 D

HPV infection

Ans. D

Explanation:

Answer- D. HPV infection
risk factor for malignant melanoma is exposure to (UV radiation)

  1. Dysplastic nevus (DN) syndrome; 5-10% risk of forming superficial spreading mil*o^u.
  2. Xeroderma pigmentosum
  3. Historyon nonmelanoma skin cancer (NMSC)
  4. Family history of melanoma (high risk)
  5. Congenital nevi

Quiz In Between



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