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CNSLF Surgery - Skin Cancers (ii) MM (Followup (NB - risk of local…
CNSLF Surgery - Skin Cancers (ii) MM
Intro
arises from melanocytes
incidence increasing @ 6% per annum
50% of all melanomas arise from pre-existing naevi
familial predisposition
affects younger people but incidence increases with age
Types
superficial spreading: often in pre-existing naevi, grow out before down, better prognosis
nodular: more aggressive, grows down, often not pigmented, usually arise de novo
lentigo maligna melanoma (Hutchison's freckle)
lentigo maligna = melanoma in siut (hasn't invaded basal layer), can progress to melanoma
acral lentiginous melanoma
palms or soles
aggressive
can affect all races (pale areas in everyone)
subungal (under nail) = 3% of melanoma cases in white pop
7 point checklist
major signs
getting larger/new one growing
irregular outline
colours are mixed shades of brown + black (colour variation within tumour)
minor signs
bigger than blunt end of pencil
inflamed or reddish edge
bleeding, oozing or crusting
starts to feel different - itchy/painful
ABCDE
Asymm in 2 axes
Border irregular
Colours (@ least 2 different ones)
Diameter (max) > 6mm
Evolution (changing)
Dx
excisional bx: 2mm margin
avoid incisional bx if possible - but sometimes no other choice for large lesions + subungal
shaving or curettage not recommended
Staging
Breslow thickness
depth correlates with survival
most important prognostic factor
vertical disease between granular layer epidermis + deepest part of MM
<0.75 - nearly 100% 5 yr survival
3+mm - 5 yr survival drops to 50%
Clark's level of invasion
more subjective
1-5 based on skin layer it has invaded into
2 = follicular dermis
4 = reticular dermis
3 = between these
TNM
Prognostic indicators
worse in males
elderly (>50)
ulceration
neovasc invasion
microscopic satellites (group of tumour cells in an area near the primary - lymphatic spread)
better prognosis if it arose in a pre-existing naevus
Tx
wide local exision +/- skin graft
all trials have failed to demonstrate statistically significant differences in overall survival + disease-free survival when comparing wide vs narrow excision
recommended margins
not always possible to achieve (e.g. if tumour on eyelid)
the greater the Breslow thickness, the greater the recommended margins
LN disease
suspicious or clinically palpable nodes: FNAC, open bx
staging
CXR
LFTs
US
CT
MRI thorax, abdo, pelvis
block dissection if dx localised to 1 lymphatic basin - little evidence of benefit, no overall survival benefit found in most studies
sentinel LN
initial LN to which the primary tumour drains
injection of radio labelled isotope around excision site the day prior + then lymphoscintigraphy looking for hot spots (gieger counter)
injection of blue dye pre-op, location of hot-spot with gamma probe
take out node + look for microscopic tumour deposits - worse prognosis
benefits on survival still controversial
done for melanoma + breast cancer
if +ve off clearance or 3 monthly surveillance with US
Adjuvant tx for mets
radio - palliative
chemo: single agent (dacarbazine) or combo
isolated limb perfusion
deliver drugs directly to site of interest
melphalan
achieve locoregional control but no survival benefit
immunotx
IFNa
IL2
ipilimumab (CTLA4 i)
PD1 i
talimogene laherparepvec (T-VEC)
BRAFi - Vemurafenib (zelboraf) + dabrafenib (tafinlar)
Followup
NB - risk of local recurrence
usually within 5cm of original lesion
3-5 yrs after primary excision
sites: skin, subcut tissue, distant Las, lung, liver, brain, bone, GIT
if in situ review once after complete excision
if invasive review every 3 months for 3yrs, if <1mm @ end of this period discharge, if >1mm continues to review every 6 months for 2 yrs
further imaging if clinical indicated