Surgical Treatment of Malignant Melanoma
Yağmur AYDIN, M.D.,Asc. Prof.
University of Istanbul, Cerrahpaşa Medical School
Department of Plastic, Reconstructive and Aesthetic Surgery
Malignant Melanoma Arise from melanocytes in basal layer in the epidermis The worst prognosis and morbidity in all skin cancers Incidence is increasing by every year (% 6 per year) accounts for only 4% of all skin cancers, but responsible
for more than 77% of skin cancer deaths Early detection and treatment important, because it
reduces the mortality and increases survival Prognosis ( 5 years) Local disease > % 90
Regional disease % 60Distant metastasis % 5
Mostly arise from skin ( 95 % ) But also found in the eyes, ears, GI tract,
leptomeninges, and mucous membranes Unknown primary or metastasis (3 %) May develop in precursor melanocytic
nevi(common, congenital, and atypical/dysplastic types (25 %)
Commonly arise from de-novo (not from a preexisting pigmented lesion)
Causes
Melanoma tends to occur at sites of intermittent, intense sun exposure
an increased worldwide incidence in fair-complexioned individuals living in sunny climates and nearer the equator, suggesting a causative role for ultraviolet radiation.
Precursor Lesions
Atypical or Displastic nevi Congenital nevi Lentigo maligna Acquired nevi
Risk Factors - I
Very fair skinned, particularly those with fair or red hair
Tendency to sun burn Excessive childhood sun exposure and
blistering childhood burns Age : the incidence steadily rises with
age. The highest incidence is in those over 80
The more moles you have on your body, the higher your risk of melanoma (more than 100 Atypical or dysplastic nevi)
The development of melanoma is multifactorial and appears to be related to multiple risk factors
Risk Factors -II Born in a hot country, such as
Australia or Israel Malignant melanoma in the first
degree relative (3-10 %) Giant congenital nevi (5-40 ) Second malignant melanoma (3-6 %) Sunbeds (Solarium) People who work outdoors and so are
in the sun (sailors, farmers ..)
People who have risk factors should be follow and have preventive efforts
Early Diagnosis
A changing mole is the most common warning sign for melanoma
Early Signs of Melanoma The most common early sign of melanoma is
pruritis A,B,C,D,E warnin signs
Asymmetry: One half of the lesion does not match the other half.
Border irregularity: The edges are ragged, notched, or blurred.
Color variegation: Pigmentation is not uniform and may display shades of tan, brown, or black; white, reddish, or blue discoloration is of particular concern.
Diameter: A diameter greater than 6 mm is characteristic, although some melanomas may have smaller diameters; any growth in a nevus warrants an evaluation.
Evolving: Changes in the lesion over time Bleeding and ulceration are late signs showing
advanced disease
All suspected lesions are removed for histopathologic examination
Biopsy
Excision (Golden standard) *İncision biopsy *Punch biopsy Partial thickness or shaving
biopsies are contraindicated
*All dermis layers should be removed
Balch CM, Houghton AN, Sober AJ, Soong S. Cutaneous Melanoma. St Louis QMP 1998
Melanoma is divided into the four major subtypes
1. Superficial spreading melanoma
2. Nodular melanoma3. Lentigo Maligna Melanoma4. Acral Lentiginous Melanoma
Superficial spreading melanoma
most common subtype of melanoma, occurring in approximately 70% of patients
most common on the trunk in men and women and on the legs in women
most commonly seen in individuals aged 30-50 years
Manifest as a flat or slightly elevated brown lesion with variegate pigmentation (ie, black, blue, pink, or white discoloration)
generally greater than 6 mm in diameter Irregular asymmetric borders are characteristic
Superficial spreading melanoma
Superficial spreading melanoma ; Level III
Superficial spreading melanoma ; Level IV
Superficial spreading melanoma ; Level IV
Superficial spreading melanoma ; Level V
Superficial spreading melanoma
The most common melanoma mimickers are seborrheic keratoses Qenign keratinocytic proliferations) and traumatized nevi, which often present as a "bleeding mole." A mole showing severely atypical features may be clinically indistinguishable from a melanoma
Superficial spreading melanoma
Nodular Melanoma Nodular melanoma is the second most common
subtype of melanoma, occurs in 15-30% of patients
Seen most commonly on the legs and trunk Rapid growth occurs over weeks to months Lack of an identifiable in situ (or radial growth)
phase Responsible for most thick melanomas Manifests as a dark brown-to-black papule or
dome-shaped nodule, which may ulcerate and bleed with minor trauma
Tends to lack the typical ABCDE melanoma warning signs
Nodular Melanoma
Nodular Melanoma : Level IV
Nodular Melanoma NÜKS
Nodular Melanoma : Level IV
Nodular Melanoma : Level V
Nodular Melanoma : Level V
Lentigo Maligna Melanoma accounts for 4-15% of cutaneous melanoma cases typically located on the head, neck, and arms
(sun-damaged skin) of fair-skinned older individuals (average age 65 y)
grows slowly over 5-20 years Only 5% to 8% of lentigo maligna are estimated to
evolve to invasive melanoma.
Lentigo maligna appears as a tan to brown macule or patch with variation in pigment or areas of regression that appear hypopigmented clinically.
Lentigo maligna melanoma is characterized by nodular development within the precursor lesion.
Lentigo Maligna Melanoma
Lentigo Maligna Melanoma
Lentigo Maligna Melanoma
Lentigo Maligna Melanoma
Level II
Lentigo Maligna Melanoma
Lentigo Maligna Melanoma
Lentigo Maligna Melanoma
Lentigo Maligna Melanoma
Acral Melanoma Acral lentiginous melanoma is the least
common subtype, representing only 2% to 8% of melanoma in Caucasians,
It typically occurs on the palms or soles or beneath the nail plate (subungual variant). Irregular pigmentation, large size (>3 cm diameter), and plantar location are characteristic features of acral lentiginous melanoma.
Acral Melanoma Subungual melanoma may be confused with
a benign junctional nevus, pyogenic granuloma, or subungual hematoma.
Rapid onset of diftuse nail discoloration or a longitudinal pigmented band within the nail plate warrants biopsy of the nail matrix, from which these melanomas arise.
The additional presence of pigmentation in the proximal or lateral nail folds (Hutchinson's sign) is diagnostic of subungual melanoma
Acral Lentiginous Melanoma
Acral Lentiginous Melanoma
Acral Lentiginous Melanoma
Histopathologic Examination
Spread of melanoma with the depth of invasion from its origin in the epidermis. There are five levels of invasion
The histopathologic classification of the Melanoma by Clark
Level I — the atypical melanocytes are confined
to the epidermis (in situ melanoma);
Level II — the atypical melanocytes have extended into
the papillary dermis but have not reached
the reticular dermis;
Level III — the atypical melanocytes have penetrated to
the interface between the papillary dermis and
the reticular dermis but do not extend into the
reticular dermis;
Level IV — the atypical melanocytes have extended
into the reticular dermis;
Level V — the atypical melanocytes have reached into the
subcutaneous fat.
Clark Clasification
The histopathologic classification of the M Melanoma by Clark
According to the thickness of the lesion as measured by an ocular micrometer
from the top of the granular zone of the epidermis to the base of the neoplasm
The histopathologic classification by Breslow
Breslow Classification
Level 1: less than 0.76 mm thick
Level 2: between 0.76– 1.50 mm
Level 3: between 1.50 - 4.00 mm
Level 3: exceed 4.00 mm in thickness
Prognostic Factors
Breslow thickness (most important) Clark invasion level Ulceration Age, sex, location Size and surgical margins Others (Mitotic index, growth phase,
regression...)
Staging
Stage I : No metastasis (Local Disease)
Stage II : Nodal metastasis (Regional Disease)
Stage III : Distant Metastasis (Systemic Diasese )
T Staging: Primary tumor thickness
T x : tm confined to the epidermis
T1 : </= 1 mm a) no ulceration, mitosis < 1mm2
b) ulceration exist, mitoz > 1mm2
T2 : 1-2 mm a) no ulceration
b) ulceration exist T3 : 2,01-4 mm a) no ulceration
b) ulceration exist T4 : >4 mm a) no ulceration
b) ulceration exist
TNM Classification AJCC 2009
TNM Classification AJCC 2009
N Staging : Lymph node status
N1 : 1 Lymph Node a) micrometastasis (SLN biopsy)
b) palpable LAP
N2 : 2-3 Lymph Node a) micrometastasis (SLN biopsy)
b) palpable LAPc) In-transit metastasis\satellit
w/o met. N3 : > 4 metastatic nodes, or matted nodes, or in transit
metastases/satellites with metastatic nodes
M Staging: Distant Metastases
M1 : Distant skin,subcutaneous or lymph node Normal LDH
M2 :Pulmonary metastases Normal
LDH
M3 : Visceral Organ or other distant metastases
Normal LDHYüksek LDH
TNM Classification AJCC 2009
Staging in Melanoma
Stage I : T1, T2, N0, M0
Stage II : T3, N0, M0
Stage III : T4, N0, M0 or Lymph node met.
Stage IV : Distant Met.
AJCC 2002
Surgical Treatment
Surgical Treatment
Biopsy Wide Local Exsicion Staging with Sentinel Lymph Node
biopsy Therapeutic Lymph Node Dissection Treatment of Distant Metastasis
Main treatment in melanoma is wide surgical excision of the tumor
Wide Surgical Excision Suggested surgical margins:
(according to breslow thickness)
In-situ MM 0,5-1 cm
Breslow thickness < 1mm : 1 cm
Breslow thickness 1-4 mm: 2 cm
Breslow thickness >4 mm: > 3 cm
• Lymphatic metastases
• Heamatogenic metastases
In-transit metastases
• Local satellite metastases
Metastases of Malignant Melanoma
Effect of Lymph Node metastases on Survival
10 years Survival%
Microscopic Lymph Node metastases
48
No Lymph Node metastases
65
Palpabl Lymph Node metastases
12
Treatment of Lymph Nodes
Wait and see (no treatment) Elective Lymph Node Dissection Sentinel Lymphadenectomy
Elective Lymph Node Dissection
Removing the regional lymph nodes for prevention in no clinical palpable lymph node
There is no consensus on survival advantage of Elective Lymph Node Dissection (ELND)
Survival advantage has been shown on retrospective studies but not in progressive studies
Complications for ELND
Early: Wound healing problems,
necrosis, and wound seperation Infection
Late: Lymphedema
Sentinel Lymphadenectomy
Sentinel Lymphadenectomy
Morton introduced for Stage I Melanoma patients in 1992
Vital blue dye intradermal injection was used for lymphatic mapping
Lymphatic drainage of primary tumor goes specific lymph node in regional lymph basin. This is the first node in the basin. This is called as sentinel lymph node
Sentinel Lymphadenectomy Sentinel lymph node shows the regional
node status If sentinel lymph node negative, others
lymph nodes in the basin are also negative
If sentinel lymph node contains tumor cells, It means disease spread to the regional nodal basin
Sentinel Lymphadenectomy
Sentinel node negative
no additional treatment, follow the patient
Sentinel lymph node positive
Therapeutic lymph node dissection
Multidiscipliner Team
Surgery Nuclear Medicine Pathology
Sentinel Lymphadenectomy
Intradermal injection of tc99 m labeled sulfur colloid and lymphoscintigraphy
intra-operative vital blu dye injection Removing blue stained and hot lymph node as
sentinel nodes Serial section of nodes, immunohistopathologic
examination by S 100, HMB 45 (melenoma spesific)
Advantages of Sentinel Lymphadenectomy Provides staging Prevents of Electice Lymph node dissection
morbidity Gives a specimen to pathologist to examine
in detail Provides psychological support Can be done by local anesthesia Less costly
Distant Metastases
Sites of Distant Metastasis
Skin Subcutaneous Tissue Distant Lymph Nodes Pulmonary Liver Brain Bone Intestine
Treatment of Distant Metastases
Soliter skin and distant lymph nodes are removed
İsoleted pulmonary metastases can be removed in selected cases
Brain and GI metastases are removed for palliation
Radiotherapy may be benefical for selected patients (mainly for pain treatment)
Treatment of Distant Metastases
Avarege life expentancy is 6-9 months There is no real treatment for Stage IV
patients Most realistic goal is palliation and
preservation of quality of life Experimental therapies may be
considered in the first line therpeutic approach
Cases
AK, E, 47 years old. Darkening of congenital nevi(1 year), biopsy : Clark Level IV, Breslow 2 mm.
Wide reexcison (1,5 cm) ve primary closure + SLN, SLN: negative
AÇ, W 48 years, DM
Nevi on the sole of the foot for 15 years, history of unhealed wound for 2 years
Biopsy at a private clinic nodular MM, Clark Level IV
•Wide excision ( 2 cm) and reconst. With SSG + SLN (2 nodes)•Breslow:17,2, Clark Level V•SLN +•Right Inguinal lymph node dissection• 1/19•Chemotherapy•Local recurrence at 6 months
18, W SE, Reexcion and ve primary closure+ SLN SLN -, Follopw –up 5 years, No diease