Malignant Melanoma

00:01 Let’s talk about malignant melanoma.

00:04 What are your risk factors? Sun exposure, especially at early age.

00:10 Blistering sunburns in childhood is a huge risk factor.

00:15 Associated with intermittent sun exposure melanoma in a first or second-degree relative also increases the risk.

00:22 And you’re worried about familial type of melanoma and neoplasia.

00:26 We talked about familial melanoma, familial type of malignant melanoma in which you’re worried about your patient who might be exposed to certain type of genes, huh? Including your p16(Ink) or maybe perhaps RAF, in fact B-Raf, right? And the name of the drug was vemurafenib.

00:48 Those at greatest risk have light hair or red hair and light eyes.

00:54 So those fair complected individuals are the ones, in which upon exposure to sun rays, are the ones that have an increased risk of going onto unfortunately malignant melanoma.

01:05 New or changing mole is something that you want to keep in mind.

01:08 And especially, if we're coming from a nevi such as your dysplastic nevus where we fulfill the criteria from A through E.

01:20 Malignant melanoma, same as those of atypical nevi.

01:24 So once, what does A mean? Asymmetry.

01:26 B means border regularity C means color variegation.

01:30 D means diameter greater than 6 millimeters.

01:33 E is evolution.

01:35 So as far as your concern, A through E, if those have been met, then high on your differential will be dysplastic nevus or you’re talking about melanoma.

01:45 How do you know? We’ll talk about this further.

01:51 With malignant melanoma in the skin, there is different types of growth that you want to pay attention to.

01:57 What does that mean? Well remember, if cancer is to grow, what are you worried about more so? Are you more worried about invasion of the cancer into the mucosa, submucosa and then going in towards lymphatic or the blood vessel? Or are you worried about differentiation or grading? Obviously, you’re worried about staging or invasion.

02:17 Why do I bring that to your attention? Because the two types of growths that we’ll take a look at are radial and vertical.

02:25 Allow the name to speak to you.

02:27 Radial, think of spokes of a wheel.

02:30 Radial growth.

02:31 Okay? That means that you’re radially growing.

02:35 Malignant melanocyte proliferation laterally along the dermoepidermal junction.

02:41 So therefore, less likely for invasion.

02:44 Therefore, typically does not metastasize if you’re referring to radial growth.

02:50 You will not refer to this, at this point, as being grading.

02:55 Radial growth.

02:56 There are melanomas that unfortunately exhibit vertical growth only.

03:03 Think of vertical.

03:04 Which direction are you moving? Invading.

03:07 So now, if you're invading, think about these malignant melanocytes, which are now invading down into the dermis and then you might then hit a blood vessel and then you’re thinking about metastasis.

03:19 Clear? Metastasis occurs at this stage.

03:23 So therefore, for management, you do everything in power to prevent your malignant melanoma from getting into a vertical growth phase.

03:33 Single most important prognostic factor is invasion, invasion, invasion, depth.

03:43 On your left is radial growth.

03:45 It remains within the dermoepidermal junction contained.

03:49 You have vertical growth on the right, would you please take a look at that body of melanocyte which is invading and vertically growing deep down into dermis and possibly increasing risk of metastasis.

04:02 In this case, guaranteed.

04:05 Now, what about malignant melanoma and epidemiology? Risk factors in the U.S. 1:65 and decreasing, 1 in 65 and getting worse.

04:17 Prognosis is best determined by depth of invasion.

04:21 Management of malignant melanoma includes complete excision of the primary lesion and any metastatic lesions if known to be present.

04:27 A sentinel lymph node biopsy is indicated if there is significant risk of regional node metastasis, which is in patients with lesions greater than 0.8 mm thickness or in smaller lesions if they are ulcerated.

04:38 Adjuvant systemic immunotherapy may be offered to patients who have undergone definitive resection of all metastatic disease.

04:45 These include checkpoint inhibitor drugs as seen on the slide, or targeted therapy against selective protein kinase pathways.

04:53 Your recommendations: Avoid UV rays.

04:58 No evidence really sunblock could decrease the risk, but nonetheless, you make the recommendation.

05:05 But you also educate that the best way to avoid this is to stay away from UV rays.

05:11 Now for testing purposes, recommended protective clothing and shady region.

05:17 Avoid peak sun hours between 10 a.m. to 4 p.m.

05:23 Make sure you know this for testing purposes, either on your boards or wards.

05:30 Differential diagnoses for melanoma: Atypical nevus.

05:34 What does that mean you? You moved on from your A, B, C, D, E fulfilling this criteria and so therefore, you’re worried about atypical nevi going in to melanoma as a differential.

05:46 Early melanomas cannot be reliably discriminated from atypical nevus.

05:50 In fact, at times, there will be a presumed diagnosis of early melanoma.

05:57 Both often will violate the ABCD principle.

06:01 Asymmetry, border variation, color variegation, D – diameter and E – evolution.

06:07 A biopsy must be performed to be certain, but be very careful though.

06:12 That will be for atypical nevus, but if you’re suspecting melanoma then biopsy can be extremely dangerous.

06:22 Seborrheic keratosis.

06:23 We’ve talked about plenty in terms of differential Yes, it could be pigmented.

06:27 It will be a stuck-on type of appearance.

06:29 And the fact that you have elderly patients in which this occurs.

06:34 May have nothing to do with exposure to UV rays.

06:37 In fact, it could be an autosomal dominant type of issue.

06:39 The last thing, once again, is that all of a sudden, if there is outcropping of these stuck-on appearance issues with the GI cancer, we call that Leser-Trélat sign.

06:52 Other differentials, actinic lentigo.

06:56 Now layman's terms called solar lentigo or liver spots.

07:01 And by that, we mean it has nothing to do with the liver but the fact that, well, on the skin it looks like liver spots.

07:07 It is a macular lesion, so therefore not palpable, of chronic sun exposure.

07:12 So now be very careful.

07:14 Apart from actinic keratosis, you have actinic lentigo which is known as your liver spot, but then once again, sun exposed area in the elderly most commonly.

07:26 Usually small, sharply circumscribed and homogenously pigmented.

07:33 It is very possible that a patient, an elderly patient, might have actinic lentigo and lipofuscin occurring on the skin at the same time.