A Tan to Die For?

Dan Magrill

Taz Singh

Laura Tincknell

Mr. RB History and Examination

Background - 53 yrs, male, unemployed PC - RIF pain HPC - RIF pain for 1/12, radiating to the back.

Loss of appetite, weight loss, tiredness, indigestion. Loose bowels 1/52, no blood or mucus. No N+V.

PMH - No THREAD. L Testicular lump 18/12 - under observation.

History and Examination cont...

FH - Paternal Grandfather - Bowel Ca. Father - Diverticulitis.

SH - Unmarried, living alone and unemployed. Smoking 20+/day. Social drinker.

SE: CVS - No chest pain, palpitations,

breathlessness, orthopnoea, collapse, nocturnal dyspnoea...

History and Examination cont...

Respiratory - No cough, wheeze, S.O.B, haemoptysis...

GI - No N+V, rectal bleeding. But had indigestion, abdo pain, loose bowels, loss of appetite and weight loss...

GU - No dysuria, frequency, haematuria, loin pain...

Neurological - No headaches, dizziness, fits, collapse, weakness...

History and Examination cont

O/E - Anxious, thin. T-37.5C, Pulse-regular, 75 bpm, BP 120/60 mmHg. O2 Sats- 97%

CVS : Unremarkable Resp: Unremarkable Neuro: Unremarkable GI: Abdomen distended. Large firm mass in

whole of abdomen apart from LIF which was tender on palpation. Liver percussed out to 35cm. BS present. PR-NAD

Plan

USS: showing multiple liver metastases. Biopsy - melanoma.

Ix to find primary: colonoscopy, CXR, ENT and opthalmology.

Opthalmology report: R eye, smooth melanotic mass in anterior chamber.

Management: Palliative Chemotherapy.

Presentation of a disease

In Incidence A Age Surgeon’s Sex Gown Geography Physicians Predisposing factors Might Macro/Micro Pathology Make Management Progress Prognosis

Incidence

UK incidence of 10 / 100 000 (per year) Rising by 7% every Year

Least common of the “Big Three”, but highest mortality.

Over last 20 years, incidence risen by over 80%

Age

Superficial Spreading and Nodular Malignant Melanoma - 20-60 year olds

Lentigo Malignant Melanoma - >60y.

Sex

In the UK, women are affected twice as often as men

In Men, the commonest site is the back In Women it is the Lower Leg (50%)

Geography

The worldwide incidence is proportional to the Geographic Latitude

Caucasians living closest to equator at highest risk

This suggests an effect of UV radiation

People living outside their indigenous climate are at risk

Predisposing Factors

Fair Skin Red Hair Living close to Equator Freckles Exposure to the Sun Melanocytic Naevus (found in 30%) Genetics - 5% of Pt have Family History

Macro/Micro Pathology 1

Superficial Spreading Malignant Melanoma– 50% of UK cases, especially female– Commonest in Lower Leg– Macular Tumour with Variable

Pigmentation

Macro/Micro Pathology 2

Nodular Malignant Melanoma– Seen in 25% of UK cases, especially Male– Commonest site is the Trunk– Pigmented Nodule– Grows rapidly and can Ulcerate

Macro/Micro Pathology 3

Lentigo Malignant Melanoma– 15% of UK cases– Malignant melanoma growing in long

standing Lentigo Maligna• These arise form sun damaged skin• Often in elderly, especially who have worked

outside for many years

Macro/Micro Pathology 4

Acral Lentiginous Malignant Melanoma– 10% of UK cases– Commonest form in Mongoloids– Tumour affects Palms, Soles and Nail

Beds– Often diagnosed late - poor prognosis

Staging

Local Staging assessed using the BRESLOW method– Measured mm between granular cell layer

and deepest identifiable melanoma cell Metastasis are uncommon if confined to

epidermis

Diagnosis

The following changes in a Naevus or Pigmented lesion– Size, usually a recent increase– Shape, irregular in outline– Colour, variation - darker or lighter– Inflammation, especially at edge– Crusting, may ooze or bleed– Itch

Differential Diagnosis

Benign melanocytic naevus Seborrhoeic wart Haemangioma Dermatofibroma Pigmented Basal Cell Carcinoma Benign Lentigo

Management 1

Surgical Excision– If <1mm, use a 1cm clearance margin– If >1mm, need a 1-2cm clearance

• As this is quite a large area a skin graft may be indicated

Regular follow up to detect recurrence– Local– Lymphatic, regional or distant– Blood Bourne - to distant sites (eg Liver)

Management 2

Elective Lymph node dissection and Sentinel node biopsy not recommended as routine.

Radiotherapy of limited use– Interferon-alfa may increase survival if

tumour >1.5mm thick

Prognosis

Related to tumour depth 5 year survival:

– <1mm 95-100%– 1-2mm 80-96%– 2.1-4mm 60-75%– >4mm 50%

Prevention and Public Education

If caught early have good prognosis Public should be encouraged to visit

doctor early if changing pigmented lesion

Sun exposure should be discouraged– Especially if fair skinned or with multiple

melanocytic naevi