malignant melanoma melanoma. malignant melanoma -malignant tumor arising from melanocytes -tendency...

Malignant melanoma

melanoma

Malignant melanoma

-malignant tumor arising from melanocytes-tendency to early lymphogenic and haematogenic metastasing

-fast increasing incidence of melanoma in the world

middle Europe 1930: 1-2 patients/ 100 000 persons1960: 5 patients/100 000 1990: 10-14 patients/100 000 2010: 14-16 patients/100 000

Australia : 60 patients/ 100 000 personsAfrica, Asia : 0,1-0,5 patients/ 100 000 persons

-Approx. men=women-54 years:average age of melanoma patient-Arising number of thin melanomas „low-risk“ due to campaigns

Pathogenesis of malignant melanoma

-genetics (FAMMM syndrome, syndrome of dysplastic naevi)

-large congenital naevi, multiple dysplastic naevi

-immunosuppression (HIV, transplantation)

-UV-light

Highest incidence and mortality: men (54 years+)Highest incidence and mortality: men (54 years+)

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Highest incidence and mortality: men (54 years+)Highest incidence and mortality: men (54 years+)

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-FAMMM syndrome(familial atypical multiple mole and melanoma) sy.-Syndrome of dysplastic naevi

Genetics

30-50% melanomas arising in a pigment mole

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Congenital naevi

N. giganteus (5-7 % risk of melanoma)

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Congenital naevi

•small 2 cm•medium-sized 2-20 cm•large -above 20 cm (MM 5-7 %)

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UV-light

-intermittent intensive UV-exposition-chronical UV-exposition(lentigo maligna melanoma, epithelial tumors)-skin fototype (I,II)-sunburns in childhood-frequent vacation (close to equator)

UVA: 320-400 nmUVB: 280-320 nmUVC: 40-280 nm

fototype sunburn pigmentation

I always never

II always sometimes

III sometimes always

IV never always

V dark skin

Distribution of melanomas in men and women

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SSM (superficial spreading melanoma)

-65 % -horizontal growth in the initial phase, later verticalization (small nodules)-relatively good prognosis due to long history

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SSM (superficial spreading melanoma)

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Nodular melanoma

- 20 % -initially smooth surface , later verrucous or ulcerating-short history due to rapid vertical growth-unfavourable prognosis

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Nodular melanoma

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Lentigo maligna melanoma

- 10 % -arising from lentigo maligna (praecancerosis)-face, hands, scalp (sun-exposed areas))-elder people-relatively good prognosis due to long history and location

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UV light

intermittent intensive UV-exposition

chronical UV-exposition lentigo maligna melanoma

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Lentigo maligna melanoma

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Acrolentiginous melanoma

- 5 %

-palms, soles, subungual, oral or genital mucosa -initially smooth surface , later verrucous or ulcerating

-bleeding due to mechanical trauma

-diff. diagnosis: subungual haemorrhage

-unfavourable prognosis

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Acrolentiginous melanoma

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Acrolentiginous melanoma

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Rare forms of melanoma

- 5 %Amelanotic melanoma-difficult diagnostics-often nodular, erodating nodules on extremities-metastases are also amelanotic

Mucosal melanoma

Occult melanoma

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Rare forms of melanoma

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Mucosal melanoma

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Diagnostics

-historyearly phase (rapid growth, change of colour, regression)late phase(bleeding, itching, inflammation, ulceration)

-ABCDE rules

-dermoscopy

-histological examination (never diagnostic incision)

ABCDE rules

asymmetry border colour diameter elevation

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Diagnostics

80 %

92-95 %Picture

Dermoscopy

•pigment network•hyperpigmentation•brown globules•blue-white veil

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Histological examination

Breslow index –exact thickness in mm

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I: tumor cells in epidermisII: tumor cells in str. papillareIII: tumor cells infiltrating upper coriumIV: tumor cells infiltrating entire coriumV: tumor cells infiltrating subcutis

Clark classification

Histological examination

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Histological examination

MelanomaMelanoma cells are in nests and have frequent mitosis

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Therapy

!Excision with safety margin!

Therapy according to the stage

High risk patients: immunotherapy interferon alfa x peptide vaccines

Visceral metastases: chemotherapy Dacarbazin (lung, liver, bones, brain)

Bone and brain metastases: irradiation

Surgery of primary melanoma

Tumor thickness

Safety margin

Tis 0,5 cm

<2 mm 1 cm

>2 mm 2 cm

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Lymph node and skin metastasis

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Skin metastasis

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Sentinel lymph node

•important for prognosis of the patient

•1.draining lymph node

I. affected SLN: radical lymphadenectomy

II. unaffected SLN: no further surgical intervention

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SLN- lymphoscintigraphy

Dosis of 0,4 ml Tc 99 as colloid Gamma camera

Lymphoscintigraphy- dynamics20 min

SLN marked with Tc

Patent blue

• Upper extremity: min. 10-20 min• Lower extremity: min. 30 min

Sentinel lymph node-patent blue

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Sentinel lymph node

I.

II.

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