3.

MALIGNANT MELANOMA
A tumour arising from melanocytes of the basal layer of the epidermis
Less commonly uveal tract (eye) and meningeal membranes

INCIDENCE
Global incidence is rising relentlessly
In NI, the incidence rate of melanoma is increasing faster than any other tumour 1996 181 new cases of malignant melanoma On average 28 deaths due to melanoma each year

RISK FACTORS FOR MELANOMA

Large numbers of benign naevi
Freckles Clinically atypical naevi Severe sunburn Early years in a tropical climate Family history of MM

PATIENT EDUCATION

FAMILY HISTORY
The majority of MMs occur in a sporadic pattern
2-10% of patients presenting with MM give a positive family history In part this may be due to the inheritance of specific MM susceptibility genes eg, CDKN2A on chromosome 9 Other reasons for familial clustering are atypical naevi and sun exposure

NAEVI
CONGENITAL NEVI occur in 1% of newborns. Tend to be large. Increased risk of MM
ACQUIRED MELANOCYTIC NAEVI 30-50% of all MMs arise in pre-existing naevi. nos of naevi=risk MM

ATYPICAL NAEVI / SYNDROME association between a familial occurrence of MM and an atypical naevus phenotype

SUNSCREENS
Have been promoted as protective agents
But this is not supported by epidemiological data ? Causal role of sunscreen chemicals

? False sense of security in those at risk spend longer out doors but dont reapply appropriately

AIDS IN CLINICAL DIAGNOSIS

GLASGOW SYSTEM
Major: Change in size Irregular pigment Irregular outline Minor: Diameter >6mm Inflammation Oozing/bleeding Itch/altered sensation

AMERICAN ABCDE SYSTEM

Asymmetry

Border
Colour Diameter Examination

TYPES OF MELANOMA

NODULAR
Commoner in males
Trunk is a common site

Usually thick with a poor prognosis

Black/brown nodule Ulceration and bleeding are common

SUPERFICIAL SPREADING
The most common type of MM in the white-skinned population 70% of cases Commonest sites lower leg in females and back in males In early stages may be small, then growth becomes irregular

ACRAL LENTIGINOUS MELANOMA

In white-skinned population this accounts for 10% of MMs, but is the commonest MM in nonwhite-skinned nations
Usually comprises a flat lentiginous area with an invasive nodular component

SUBUNGAL MELANOMA
Rare
Often diagnosed late confusion with benign subungal naevus, paronychial infections, trauma

Hutchinsons sign spillage of pigment onto the surrounding nailfold

LENTIGO MALIGNA MELANOMA

Occurs as a late development in a lentigo maligna Mainly on the face in elderly patients May be many years before an invasive nodule develops

AMELANOTIC MELANOMA
Diagnosis is often missed clinically The lack of pigmentation is due to the rapid growth of the tumour and the differentiation of the malignant melanocytes

METASTATIC MELANOMA

PROGNOSTIC VARIABLES
The Breslow thickness is the single most important prognostic variable (distance in mm of the furthest tumour cell from the basal layer of the epidermis)
Breslow depth In situ <1mm 1-2mm 5 year survival 95-100% 95-100% 80-96%

2.1-4mm
>4mm

60-75%
50%

 Scalp lesions worse prognosis, then palms and soles, then trunk, then extremeties Younger women appear to do better than either men at any stage or women over 50 Ulceration of the tumour surface is a high risk factor

MANAGEMENT
Surgical excision 1-3cm margins depending on breslow depth
Invasive primary MM on the digits can be treated by amputation Need to investigate all MMs over 1mm for metastases CXR, USS abd or CT chest, abd, pelvis, bloods FBP, LFTs, LDH New scanning modality in Belfast PET scan for high risk primaries or evaluating lymphadenopathy

FOLLOW UP
No general agreement on time period
Depends on tumour thickness Thick tumours 5-10 years Need to examine the scar and check for lymphadenopathy, liver, spleen, and total body examination for other suspicious naevi

PLANTAR MALIGNANT MELANOMA

Caucasians 1-9%
Asians 29-46% Afro-Carribean 6070%

SUBUNGAL MELANOMA
TRAUMA

Dwyer PK et al British Journal of Dermatology 1993;128:115-120

51 white caucasian patients west of Scotland with plantar melanoma 20 sup spreading melanoma 27 acral lentiginous 4 nodular Female:male 3:2
Thickn 5 yr -ess surv foot 0-1.49 82%

5 yr surv leg 95%

1.53.49
>3.5

51%
0%

71%
46%

Franke W et al Melanoma Research 2000;10:571-576

Type Age of MM foot 63.3 Thickn Prognosis for plantar melanoma poor -ess 2.55
Poor survival can be improved by a significant reduction in the time period between the first observation of a plantar skin lesion and surgical treatment

Rest of 52.6 body

1.22

Walsh SM et al The Journal of Foot and Ankle Surgery 2003;42(4):193-198

..that the clinician must maintain a high index of suspicion when a patient presents with a pigmented or atypical lesion on the foot.