Melanoma

Alan L. Cowan, MD

Faculty Advisor: Anna M. Pou, MD

The University of Texas Medical Branch

Department of Otolaryngology

Grand Rounds Presentation

March 10, 2004

Melanoma

Almost 30% of all melanomas arise in the head

and neck

Widespread use of sunscreen has not lowered

the incidence.

Incidence is increasing almost 5% per year

Approximately 47,000 new cases in 2001

Predisposing Factors

Sun Exposure

Age, frequency, severity of exposure may play a role

Sunscreen use may not be protective

Familial Melanoma / DNS

Family members have almost 50% chance of developing melanoma

Lesions may be multiple and in sun shielded areas

Xeroderma Pigmentosa

Predisposes to several types of skin cancer

Skin malignancies often appear by age 10

Sunlight

UVB (280-320nm)

Causes direct DNA damage

Originally thought to be primary factor

Blocked by current sunscreens

UVA (320-400nm)

Causes indirect DNA damage via free radicals

Some now consider as more important than UVB

Sunscreen has little UVA protection

Types of Melanoma

Superficial Spreading

Most common

Cells atypical but uniform in appearance

Nodular

Early invasion due to vertical growth

Acral Lentiginous

Appears on palms and soles

Histology shows heavily pigmented dendritic processes in the basal layer

Types of Melanoma

Desmoplastic May lack pigment

Peri-neural invasion is classic

Histologic exam may show “school of fish” appearance

Lentigo Maligna Melanoma May remain in-situ for decades

Can spread along hair follicles

Mucosal Often lack melanin

Conventional staging system does not apply

Site of lesion corresponds to prognosis

Nasal cavity best prognosis, 31% at 5-yrs

Paranasal sinuses worst prognosis, 0% at 5-yrs

Diagnosis

History

Family History

Sun exposure

Bleeding, pain

Physical

ABCD

Histology

H&E

S-100, HMB-45

Biopsy

Excisional

Recommended for small lesions

Margins of 2mm

Incisional

For larger lesions

Does not alter draining lymphatics

Punch

Same as incisional

Shave

Contraindicated

Needle

Contraindicated

Clark staging

Based upon histologic level of invasion

Level I – Epidermis only (in situ)

Level II – Invades the papillary dermis, but not to the

papillary-reticular interface

Level III – Invades to the papillary-reticular interface,

but not into the reticular dermis

Level IV – Into the reticular dermis

Level V – Into subcutaneous tissue

Breslow staging

Based upon absolute depth of invasion

Stage I – < 0.75 mm

Stage II – 0.76 – 1.5 mm

Stage III – 1.51 – 4.0 mm

Stage IV - > 4.0 mm

AJCC staging

AJCC staging

AJCC staging

Prognosis by AJCC stage

Stage I < 0.75 – 96 %

0.75 – 1.5 – 87 %

Stage II 1.5 – 2.49 – 75 %

2.5 – 3.99 – 66 %

> 4.0 – 47 %

Stage III One node 45 %

Two nodes < 20 %

Stage IV 8 – 10 %

Percentages are five year survival except stage IV lesions which represent one year survival

Treatment - Stage I

Labs

LDH

Radiology

CXR

Excision

1 cm margins

Adjunctive Therapy

None

Treatment - Stage II

Labs LDH

Radiology CXR

Possible CT for metastasis

Possible Lymphoscintigraphy

Excision 2 cm margins

Adjunctive Therapy Possible elective neck dissection

Possible sentinel lymph node biopsy

Possible elective radiation

Treatment - Stage III

Labs LDH

Possible LFT’s

Radiology CXR

CT neck

Possible CT abdomen, MRI brain

Excision 2 cm margins

Remove in-transit lymphatic basins

Neck dissection directed by site Posterolateral vs. Lateral vs. Supraomohyoid

Adjunctive Therapy Probable radiotherapy

Possible chemotherapy

Treatment - Stage IV

Labs CBC, LFT’s, LDH

Radiology CT Chest, Abdomen, Pelvis

MRI brain

Excision 2 cm margins

Remove in-transit lymphatic basins

Neck dissection directed by site Posterolateral vs. Lateral vs. Supraomohyoid

Adjunctive Therapy Radiation therapy

Consider chemotherapy as part of a clinical trial

Neck Dissection

Neck Dissection

Posterolateral ND

Lesions in occipital and posterior scalp areas

Lateral ND

Lesions on temple, forehead, anterior scalp

Supraomohyoid

Lesions of anterior face

Follow-up

Sentinel Lymph Node Biopsy

Used to determine nodal status in low-risk

tumors

Allows for limited surgical morbidity.

Has prognostic value for patient outcome

Sentinel Lymph Node Biopsy

Procedure

Preoperative lymph basin mapping using

lymphscintigraphy with Tc99

Preoperative injection of radiotracer allows for

intraoperative gamma counter localization

Intraoperative injection of iosulfan blue allows for

visual detection of involved nodes.

Allows for detection of sentinel nodes in 88-99% of

patients depending on the study cited.

Sentinel Lymph Node Biopsy

Incidence of positive SLNB ~12%

False negative rate < 2%

Three year survival rates for negative vs. positive SLNB were 96.8% and 69.9%, respectively

Multivariate analysis has shown that positive SLNB predicts survival more accurately than depth

Elective neck dissection has not been found to change outcome if SLNB is negative

Positive SLNB patients may be candidates for radiation therapy

Sentinel Lymph Node Biopsy

Recurrence following negative SLNB is most

commonly in the assesed lymphatics.

Gershenwald found that 80% of his regional

recurrences actually had melanoma in the

biopsied gland, but were missed on analysis

Use of S-100 or HMB-45 increases the

diagnostic value and may lower the false

negative rate.

Radiation

Indications include stage III or IV lesions

Patients with positive SLNB should be

considered

Decreases local recurrence rates to 85-88%

Does not affect overall survival

May be contraindicated for lesions near the eye

or for midline lesions

Chemotherapy

Numerous therapy modalities exist

No significant benefit has been found for any

therapy to date

Administration of chemotherapy should be done

as part of an ongoing clinical trial.

Bibliography

Lentsch, Eric; Myers, Jeffrey. “Melanoma of the Head and Neck: Current Concepts in Diagnosis and Management.” The Laryngoscope July 2001, 111:1209–1222.

Haywood, Rachel; Wardman, Peter; Sanders, Roy; Linge, Claire. “Sunscreens Inadequately Protect Against Ultraviolet-A-Induced Free Radicals in Skin: Implications for Skin Aging and Melanoma?” The Journal of Investigative Dermatology. 121:862-868, 2003.

Greene, Mark; et al. “High Risk of Malignant Melanoma in Melanoma-Prone Families with Dysplastic Nevi.” Annals of Internal Medicine. 102: 458-465, 1985.

Gershenwald, Jeffrey; et al. “Multi-Institutional Melanoma Lymphatic Mapping Experience: The Prognostic Value of Sentinel Lymph Node Status in 612 Stage I or II Melanoma Patients.” Journal of Clinical Oncology. 17 (3), 199:pp 976-83.

Bibliography

Gershenwald, Jeffrey; et al. “Patterns of Recurrence Following a Negative Sentinel Lymph Node Biopsy in 243 Patients With Stage I or II Melanoma.” Journal of Clinical Oncology. 16 (6), 1998: pp 2253-60.

Ang, K.; et al. “Postoperative Radiotherapy for Cutaneous Melanoma of the Head and Neck Region.” International Journal of Radiation Oncology. 30 (4) 1994: pp 795-98.

Braud, Filippo; et al. “Malignant Melanoma.” Critical Reviews in Oncology/Hematology. 47 (2003) 35-63.

Alex, James C. “The Application of Sentinel Node Radiolocalization to Solid Tumors of the Head and Neck: A 10-Year Experience.” The Laryngoscope. 2004 Jan;114(1):2-19.

Fauci, Anthony S.; et al. “Melanoma and Other Skin Cancers”. Harrison’s Principles of Internal Medicine. Chapter 88 McGraw-Hill, San Francisco, California. 1998.

Bailey, Byron. “Melanoma of the Head and Neck”. Head and Neck Surgery – Otolaryngology. J.B. Lippincott Company, Philadelphia, PA. 1993 pp1082-1090.

Melanoma

Alan L. Cowan, MD

Faculty Advisor: Anna M. Pou, MD

The University of Texas Medical Branch

Department of Otolaryngology

Grand Rounds Presentation

March 10, 2004