Let’s talk about
What are your risk factors?
Sun exposure, especially at early age.
Blistering sunburns in childhood
is a huge risk factor.
Associated with intermittent
sun exposure melanoma
in a first or second-degree
relative also increases the risk.
And you’re worried about familial
type of melanoma and neoplasia.
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.
Those at greatest risk have light
hair or red hair and light eyes.
So those fair
are the ones, in which
upon exposure to sun rays,
are the ones that have
an increased risk of
going onto unfortunately
New or changing mole is something
that you want to keep in mind.
if we're coming from a nevi
such as your dysplastic nevus
where we fulfill the
criteria from A through E.
Malignant melanoma, same
as those of atypical nevi.
So once, what does A mean?
B means border regularity
C means color variegation.
D means diameter greater
than 6 millimeters.
E is evolution.
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.
How do you know?
We’ll talk about this further.
With malignant melanoma in the skin,
there is different types of growth
that you want to
pay attention to.
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.
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.
Allow the name to speak to you.
Radial, think of spokes of a wheel.
That means that you’re
along the dermoepidermal
So therefore, less
likely for invasion.
typically does not metastasize if
you’re referring to radial growth.
You will not refer to this, at
this point, as being grading.
There are melanomas that unfortunately
exhibit vertical growth only.
Think of vertical.
Which direction are you moving?
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.
Metastasis occurs at this stage.
for management, you do everything in power
to prevent your malignant melanoma from
getting into a vertical growth phase.
Single most important prognostic factor
is invasion, invasion, invasion,
On your left is radial growth.
It remains within the
dermoepidermal junction contained.
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.
In this case, guaranteed.
Now, what about malignant
melanoma and epidemiology?
Risk factors in the U.S.
1:65 and decreasing,
1 in 65 and getting worse.
Prognosis is best determined
by depth of invasion.
reason that transection
during biopsy is avoided
because, oh my goodness,
you’re worried about
spreading the cancer
Early intervention is key, no doubt.
So therefore, as soon as you
have a patient who is Caucasian
and you start noticing
a mole or nevi,
you always want to make sure that you
follow up and you have correctly diagnosed
what kind of nevus this is and to make
sure that it has not gone through
or is not going through
Recommendation for this population
would be to avoid the sun
or limit exposure to UV rays.
Excision is only viable
treatment option at present.
Well, as I told you earlier, there
is something called vemurafenib.
Now metastasis is your
harbringer of poor outcome.
As soon as metastasis kicks in, lymph node,
lungs and liver are the most common.
Lymph node, lungs, and liver,
L-L-L, are the most common.
In terms of chemotherapy, there is
something that you want to keep in mind
in current day practice in which based on a
philosophy called oncogenic addiction.
In which you have a cancer which is
addicted to one particular mutation
which is rather rare,
but we use it to our
and with B-Raf with familial
being extremely effective.
That if you knock out the
B-raf with vemurafenib
that we have seen positive results
with such patients of treating
familial type of melanoma.
Diagnosis and management:
A suspected melanoma should be diagnosed
by excision of entire lesion,
Consider a sentinel lymph
node biopsy for lesion
with a Breslow depth of
greater than 1 millimeter.
Know this in great detail,
extremely common in melanoma.
Wide local excision of primary lesion.
And adjuvant therapy for
and we’ve talked about while
there is interferon-alpha,
but in addition, there is also vemurafenib
that I’ve mentioned a few times.
And I’ve also discussed in
your neoplasia discussion.
Your recommendations: Avoid UV rays.
No evidence really sunblock
could decrease the risk,
but nonetheless, you
make the recommendation.
But you also educate that the best way to
avoid this is to stay away from UV rays.
Now for testing purposes, recommended
protective clothing and shady region.
Avoid peak sun hours between 10 a.m.
to 4 p.m.
Make sure you know this for testing
purposes, either on your boards or wards.
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.
Early melanomas cannot be reliably
discriminated from atypical nevus.
In fact, at times, there will be a
presumed diagnosis of early melanoma.
Both often will violate
the ABCD principle.
Asymmetry, border variation,
D – diameter and E – evolution.
A biopsy must be performed to be
certain, but be very careful though.
That will be for atypical nevus,
but if you’re suspecting melanoma then
biopsy can be extremely dangerous.
We’ve talked about plenty
in terms of differential
Yes, it could be pigmented.
It will be a stuck-on
type of appearance.
And the fact that you have elderly
patients in which this occurs.
May have nothing to do
with exposure to UV rays.
In fact, it could be an autosomal
dominant type of issue.
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.
Now layman's terms called solar
lentigo or liver spots.
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.
It is a macular lesion, so therefore
not palpable, of chronic sun exposure.
So now be very careful.
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.
Usually small, sharply circumscribed
and homogenously pigmented.
It is very possible that a
patient, an elderly patient,
might have actinic
lentigo and lipofuscin
occurring on the skin
at the same time.