Management of Melanoma

by Stuart Enoch, PhD

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    00:01 Now, we've done that. We've done an excision biopsy. Leave that for one minute, I'll come back to that. You've done an excision biopsy, and that comes up as a let's say, 2.1 mm Breslow thick melanoma. Then you'd go for excision margin of two to three centimetres. So in your exam, if they ask you, patient has come with a Breslow thickness of seven millimetres, it's pretty much impossible for you to remember this.

    00:37 You won't remember because even when we work in plastics, we just won't remember every measurement, but have in your head, up to two millimetre; two to three centimetres, two centimetre is fine. Anything more than two millimetre, go for three. Leave that for a minute because it's quite important to get the margins for melanoma. Two millimetre Breslow depth; two centimetre margin. More than two millimetre Breslow depth, three centimetre margin. Sentinel node biopsy. Who knows about sentinel node? What's the definition of sentinel node biopsy? It’s the first node to be drained by the -- Tumour? Okay. Is it diagnostic or therapeutic? Diagnostic. Diagnostic. And it really hasn't got any prognostic value as well. It's more of a diagnostic tool. What are the contraindications for sentinel node, from which areas you don't do a sentinel node biopsy? Groin? No, groin you do. Head and neck. Because the head and neck drainage is so variable, you don't know which way it's going to drain into.

    01:59 So sentinel node is mainly done for the limbs, very commonly, breast, and maybe for the trunk.

    02:06 Anything in from back is also very very, you don't know if it's going to drain the neck, axilla or the groin. It is most significant for the limbs.

    02:18 Okay, management of melanoma. Now, I’m not sure whether I should cover this because it might be bit too detailed for you regarding melanoma. I don't think they’re asking you this much of detail. They'll ask you Breslow depth but I don't think they’ll go into management or further investigations. So I'll just skip this slide. And go to the last bit, this one. Management options are surgery plus radiotherapy. Chemotherapy only for advanced disease. Biopsy proven melanoma we've discussed. Up to 2 mm: 2 cm; more than 2 mm: 3 cm.

    03:10 So BCC is three to five millimetre, SCC is six to ten millimetre. Melanoma, one to two centimetre. Okay we are on the last bit now. We are almost done.

    03:32 Vascular. Now, this I’m going to skip through quickly. Venous ulcer. I won't spend too much time show you all the images. If I give you the history, you'll be able to understand. Venous ulcer, classically in the medial gaiter area of the leg, usually have sloping margins. They may have surrounding cellulitis or some dermatitis. What is the single most appropriate treatment for venous ulcer? Compression bandage? Compression. Four layered compression bandage, after ruling out arterial disease. That's correct. Four layered compression bandage.

    04:08 What are the changes you can see in a venous ulcer? Lipodermatosclerosis, haemosiderin deposition, atrophic blanch. And shiny, no, shiny skin is for arterial. Varicose eczema, yes. So these are things you need to look for. So I’ll just go through the bits.

    04:28 Rest, elevation, control infection, moisturise. That are all basic things. Single most one is compression bandage for venous. That's it. Four layered compression bandage that's what they're looking for. And what do you do before that? So haemosiderin deposition, lipodermatosclerosis, atrophic blanch; what is atrophic blanch? Atrophic blanch is this white scars you'll get with recurrent ulceration and healing. They're painful.

    05:09 And this is the inverted champagne bottle leg. Where do you get that? Because the bandage slips to the calf and they end up with this sort of leg. So in your exam if they give you any of these terminologies, it's venous. So there's a sixty four year old lady presenting with ulceration over the medial maleolus or thereabouts, with surrounding lipodermatosclerosis.

    05:33 Don't waste time, venous. Nothing else. What's this? Arterial. Why is it arterial? It’s punched out. Okay, a bit of punched out, what else can you see? Shiny skin. Okay, what else would you expect? Loss of hair. What happens in the nails? Loss of toe nail or atrophic nails. Skin changes, dusky skin, loss of hair, cool to touch, brittle nail or opaque nail, loss of nail. So if they give you any of these features in the exam, go for arterial. History you'll focus on or what other history they will give you? Risk factors. Other arterial diseases.

    06:22 So, smoker, systemic arterial disease, patient presented with IC - intermittent claudication, rest pain, other sites of ulceration. You can't miss this because if they give any of this, arterial. Bang. Investigation. Let's say you have seen a patient with arterial disease or peripheral arterial disease, what's the next investigation, first thing you do? So, you do the ABPI first. Formal ultrasound, what is it called? Duplex. What's the next investigation? CT or angiogram. CT angiogram or just angiogram.

    07:01 This is an old form of angiogram, but we do a CT angiogram now.

    07:09 ABPI measurements. Do you know these values? What are the risk factors for any arterial disease? Hypercholesteremia, smoking, obesity, hypertension, diabetes. What are non-modifiable risk factors? Age, gender, positive family history. Increase in age, male sex, male gender, male sex and positive family history. Those are non-modifiable. And these are modifiable risk factors. If they ask you a question related to surgery in arterial disease, what are the features you need to look for? When do you operate on somebody with arterial disease? If they're presenting with intermittent claudication, disabling intermittent claudication, critical ischemia, rest pain, gangrene. These are all absolute indications. So non-healing, recurrent ulceration with infection, disabling claudication, rest pain, gangrene. All these are indications for offering surgery.

    08:33 Diagnosis? Gangrene.

    08:41 Dry or wet? Dry. Management? Auto amputation, conservative. That's fine.

    08:50 Prevent infection, allow to auto-amputate.

    08:53 Diagnosis? Gangrene, wet gangrene. Tell me why you say its wet gangrene? Tell me three features you can see. Oedema, blisters, and cellulitis. So this is moist gangrene, or wet gangrene.

    09:16 Management? Amputation, no not so quickly.

    09:22 First elevate at least -- I'm not sure, why do you want that? You mean anticoagulation? Sure.

    09:33 So, 24 to 48 hours of IV first and then you have to consider surgery if it is progressing or getting worse. So consider control of proximal spread of infection, sepsis control, consider improving circulation. What's the risk of amputation in this patient without controlling infection? What is the risk of amputating or doing surgery without controlling the infection? Because the wound will get infected. Spread of the wound, the wound will get infected. So you need to make sure that the infection is under control before you operate. Okay this a diabetic foot ulcer. Fine. What's the single most thing in management? There are two things. Control diabetes, good glycaemic control, and secondly, pressure relief. What did you say? Osteomyelitis, fine. Yes.

    10:44 So diabetic ulcer investigations. FBC/UC&Es, glucose, HbA1C, x-ray. Okay. Doppler, duplex, depending on what it is. Management, glycemic control, supervening, prevent infection and pressure relief. Other aetiologies will be just to confuse

    About the Lecture

    The lecture Management of Melanoma by Stuart Enoch, PhD is from the course Medical Scenarios.

    Author of lecture Management of Melanoma

     Stuart Enoch, PhD

    Stuart Enoch, PhD

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