Melanoma

Melanoma malignan
Yulia farida Yahya Dep I Kesehatan Kulit & kelamin FK UNSRIRSUP M Hoesin Palembang

Clinical findings
Sub-type melanoma • Superficial spreading melanoma (SSM) most common sub-type • Accounting approximately 70% off all cutaneous melanoma • Most commonly 4th & 5th decades on intermitten sun exposed areas • Most frequently lower back of men & lower extremity of women

Clinical findings
• In the classic clinical appearance best fits into ABCD criteria making diagnosis • Lesion with irregular borders & irregular pigmentation, subtly as discreta focal area of darkening within pre-existing nevus

SSM classic appearance

Superficial spreading melanoma
A. SSM, Breslow depth 0,51mm
B. Amelanotic SSM, upper back, Breslow depth 0,38 mm C. Unusual SSM,posterior shoulder, deep 11 X 9mm,Breslow deep 1,60mm D. Unusual SSM, right ankle, Breslow depth 6,3mm

Differential diagnosis SSM

Nodular melanoma (NM)
Second most common melanoma subtype Approximately 15% - 30% of all melanoma The median age of onset 53 years The most common site trunk NM typicallyuniformly dark blue-black or bluis-red raised lesion, 5% amelanotic

Nodular melanoma
A. Classic nodular melanoma,left lower back, Breslow deep 4,3mm B. Classic nodular melanoma,left lower back, Breslow deep 16mm C.Amelanotic NM,Breslow deep2,37mm

D. Amelanotic NM,right posterior shoulder,Breslow depth 3,95mm

Differential Diagnosis Nodular melanoma

Nodular melanoma

Making diagnosis

♥Clinical diagnosis made in only 80-90% of cases ♥ The well known ABCDE acronym for melanoma detection developed 1925  useful tool for public & physician

Dermoscopy
•  epiluminecence, dermatoscopy, incident light microscopy, surface microscopy • Simple, non-invasive technique in which a liquid, ussually immersion oil applied to lesion examined with handle-held lens (magnification ussually 10X) or commercialy available device • Sensitivity & specificity for clinical diagnosis of malanoma other pigmented & non pigmented lesions

Close inspection with dermascope

SSM Without oil immersion

With oil immersionthe pigment network, brown globul, pseudopods, depigmented,extending irregularly

Immunohistochemistry
• Useful for diagnosis melanoma especially inpoorly differentiated neoplasma with litle or no pigment ( i,e amelanotic melanomas), spindle cell tumors or tumor with pagetoid spread that are not obviosly melanoma • S100 protein expressed virtually all melanoma, melanocytic nevi, langerhans cell, cutaneous neural tumors • HMB 45 monoclonal antibody with high specificity for melanoma • Melan-A & MART-1(melanoma recognized by Tcell)

Melanoma TNM Classification

Treatment
• Surgery wider excision (WLE)  prevent local recurrence to confirm tumor free margin, inadequat excision potential lethal • Treatment regional metastasis complete lymph node dissection (CLND) • Adjuvant therapyinterferon-α 2b high doses

Treatment
• Immunotherapy high dose bolus interleukin 2 (IL-2) • Biochemotherapy vaccine combination other systemic agent (dacarbazine or IL-2) • Melanoma Vaccine  autologous,allogeneic, peptide vaccines unfortunately without significant progress

Prognosis
• AJCC classification system TNM categories • Tumor Thickness  originally by Breslow  thickness is measured from top granular layer epidermis to the greatest depth tumor invasion using color micrometer & measured in mm survival decreased with increasing Breslow depth

Prevention
• Safe sun exposurelimited UV exposure & sun burn prevention especially childhood & adolescent have risk is greatest • Avoidance peak sunlight hours • Use wide-brimmed hats • Clothing & sunscreen recommended • Early diagnosis & knowledge early signs & symptoms of melanoma reduced morbidity & mortality