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Malignant Melanoma

by Carlo Raj, MD
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    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 elevation.

    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.

    04:20 So therefore, reason that transection during biopsy is avoided because, oh my goodness, you’re worried about spreading the cancer cells deeper.

    04:31 Early intervention is key, no doubt.

    04:33 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 dysplastic changes.

    04:49 Recommendation for this population would be to avoid the sun or limit exposure to UV rays.

    04:57 Excision is only viable treatment option at present.

    05:00 Well, as I told you earlier, there is something called vemurafenib.

    05:06 Now metastasis is your harbringer of poor outcome.

    05:09 As soon as metastasis kicks in, lymph node, lungs and liver are the most common.

    05:14 Lymph node, lungs, and liver, L-L-L, are the most common.

    05:19 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.

    05:29 In which you have a cancer which is addicted to one particular mutation which is rather rare, but we use it to our advantage clinically and with B-Raf with familial being extremely effective.

    05:42 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.

    05:56 Diagnosis and management: A suspected melanoma should be diagnosed by excision of entire lesion, not biopsy.

    06:06 Consider a sentinel lymph node biopsy for lesion with a Breslow depth of greater than 1 millimeter.

    06:13 Know this in great detail, extremely common in melanoma.

    06:17 Wide local excision of primary lesion.

    06:20 And adjuvant therapy for metastatic diseases and we’ve talked about while there is interferon-alpha, but in addition, there is also vemurafenib that I’ve mentioned a few times.

    06:31 And I’ve also discussed in your neoplasia discussion.

    06:38 Your recommendations: Avoid UV rays.

    06:43 No evidence really sunblock could decrease the risk, but nonetheless, you make the recommendation.

    06:50 But you also educate that the best way to avoid this is to stay away from UV rays.

    06:56 Now for testing purposes, recommended protective clothing and shady region.

    07:02 Avoid peak sun hours between 10 a.m. to 4 p.m.

    07:07 Make sure you know this for testing purposes, either on your boards or wards.

    07:15 Differential diagnoses for melanoma: Atypical nevus.

    07:18 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.

    07:31 Early melanomas cannot be reliably discriminated from atypical nevus.

    07:35 In fact, at times, there will be a presumed diagnosis of early melanoma.

    07:41 Both often will violate the ABCD principle.

    07:46 Asymmetry, border variation, color variegation, D – diameter and E – elevation.

    07:52 A biopsy must be performed to be certain, but be very careful though.

    07:57 That will be for atypical nevus, but if you’re suspecting melanoma then biopsy can be extremely dangerous.

    08:07 Seborrheic keratosis.

    08:08 We’ve talked about plenty in terms of differential Yes, it could be pigmented.

    08:12 It will be a stuck-on type of appearance.

    08:13 And the fact that you have elderly patients in which this occurs.

    08:19 May have nothing to do with exposure to UV rays.

    08:21 In fact, it could be an autosomal dominant type of issue.

    08:24 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.

    08:37 Other differentials, actinic lentigo.

    08:40 Now layman's terms called solar lentigo or liver spots.

    08:45 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.

    08:52 It is a macular lesion, so therefore not palpable, of chronic sun exposure.

    08:57 So now be very careful.

    08:59 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.

    09:11 Usually small, sharply circumscribed and homogenously pigmented.

    09:17 It is very possible that a patient, an elderly patient, might have actinic lentigo and lipofuscin occurring on the skin at the same time.


    About the Lecture

    The lecture Malignant Melanoma by Carlo Raj, MD is from the course Neoplastic Skin Diseases.


    Included Quiz Questions

    1. Excision of entire lesion
    2. X-ray
    3. Complete Blood Count
    4. CT Scan
    5. Ultrasound
    1. Gastrointestinal system
    2. Liver
    3. Lungs
    4. Brain
    5. Heart
    1. Actinic lentigo
    2. Seborrheic keratosis
    3. Melanoma
    4. Compound nevus
    5. Dysplastic nevus
    1. Vertical growth of the lesion
    2. large sized lesion
    3. Radial growth of lesion
    4. Dark colored lesion
    5. Young age of the patient

    Author of lecture Malignant Melanoma

     Carlo Raj, MD

    Carlo Raj, MD


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