malignant melanoma
TRANSCRIPT
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Melanoma Precursors & Primary
Cutaneous MelanomaNurul Shuhada bt Mohd Nazari
030369
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Precursor of cutaneousmelanoma
Cutaneousmelanoma
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Precursor of cutaneous melanoma
• Lesions that are benign with potential of turning into malignant
1. Dysplastic Melanocytic Nevus
2. Congenital Nevumelanocytic Nevus
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1. Dysplastic Melanocytic Nevus
• Atypical Melanocyte Nevus
• Acquired, circumscribed, pigmented lesion due to proliferation of atypical melanocyte
• Arise from
1. De novo
2. Melanocytic Nevi
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Epidemiology
• Age & onset : children & adult
• Prevalence : 5% in white population
• Sex : equal in males and females
• Race : white. Rare in Japanese
• Transmission : Autosomal dominant
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Pathogenesis
Sunlight exposure
Activation of abnormal clone of melanocyte
• Immunosuppressive patient such as renal transplant with DN have higher incidence of melanoma
• Favor part : exposed area ( eg. Back) . May also occur in covered area
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Clinical Manifestation
• Duration ▫ later in childhood ▫ Do not undergo spontaneous regression
• Skin symptom ▫ Asymptomatic ▫ “Out of step” : mixture of large and small, flat and
raised, tan and very dark lesion
• Family history ▫ Family member can develop melanoma even
without DN
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Note a number of lesions are of different size and color, “out of step”.Note irregularity, variegation of color which are different in the two lesions (“outof step”).
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How to differentiate between DN and
other common acquired nevi?
• Larger & more variated in colour
• Asymmetrical
• Irregular border
• Characteristic histological feature
However no single feature is diagnostic
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Laboratory Examination
• Dermatopathology
1. Atypical melanocyte
Hyperplasia
Proliferation disorder
2. Lentiginous pattern in basal cell layer
3. Atypical melanocyte bridging between cell layer
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Management
• Surgical excision
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2. Congenital Nevomelanocytic Nevus
• Congenital, clinically apparent during infancy
• Vary in size (small → large )
• Benign nevomelanocyte neoplasm
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Epidemiology
• 1 % of white newborn
• Age of onset
▫ Congenital
▫ Some present after birth (tardive)
• “fading in” pattern → relatively large lesion over period of weeks
• Sex : Equal male and female
• Race : all race
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Pathogenesis
• Developmental defect in neural crest-derived melanoblast
Small Giant
Distort the skin surface to some degree
Plaque with or without terminal dark brown/ black hair
Sharply demarcated
Involve majority of skin
Complete replacement of skin on back and smaller CNMN on buttock & thigh
Rugose
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• Colour
▫ Light or dark brown, black.
▫ With dermoscopy, fine specking of darker hue with lighter surrounding brown hue.
• Size
▫ Small, large, giant
• Shape
▫ Oval and round
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Small, variegated brown plaque on the nose. Thelesion was present at birth. Note that lesion is hairy.Congenital nevomelanocytic nevus, intermediate size.Sharply demarcated chocolate-brown plaque with sharply defined borders in an infant. With increasing age,lesions may become elevated and hairy and very discrete hairiness is also noted in this lesion
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Giant CNMN
• At the head and neck
• Associated with involvement of leptomeningitiswith same pathological process
• May be asymptomatic or manifest as seizure, focal neurologic defect or obstructive hydrocephalus
• A plaque with surface distortion, covering entire segments of the trunk, extremities, head or neck.
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the lesion involves the majority of the skin,with complete replacement of normal skin onthe back and multiple smaller CNMN on thebuttocks and thighs
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Laboratory
• Nevomelanocyte→ well ordered cluster in epidermis
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Treatment
• Surgical excision
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Cutaneous Melanoma
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Introduction
• Most malignant tumor of skin
• Arise from malignant transformation of melanocyte at dermal epithelial junction
• Nevomelanocyte of DN of CNMN that become invasive and metastasis after various time interval
OR
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Epidemiology
• Genetic predisposition chromosome 9p21
• Sun exposure
▫ Exposure to solar radiation
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Risk Factor
• Genetic markers (CDKN2a mutation)
▫ Skin type I/II
▫ Family history of dysplastic nevi or melanoma
▫ Personal history of melanoma
▫ Ultraviolet irradiation, particularly sunburns during childhood and intermittent burning exposures
• Number (>50) and size (>5 mm) of melanocytic nevi
• Congenital nevi
• Number of dysplastic nevi (>5)
• Dysplastic melanocytic nevus syndrome
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Melanoma Recognition 6 signs of malignant melanoma
• A → assymmetry• B → border irregular
edges irregularly developed, sharply defined
• C → colour. Not uniform, mottled, all shades of brown, black, grey, blue, red or white
• D → Diameter. Large greater than 6mm • E → Elevation. Surface distortion
Evolving . Increase in size of lesion
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4 major types of melanoma
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1. Superficial Spreading Melanoma
• Commonly arise at upper back and occurs as a moderately slow-growing lesion over a period of up to 2 years
• Distinctive Morphology :
▫ Elevated, flat lesion (plaque)
▫ More striking pigment variegation
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Epidemiology
• Age : 30-50 y/o
• Sex : slightly higher incidence in female
• Race : white-skinned people
• Incidence : 70 %
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Pathogenesis
• Intraepidermal/ radial / early phase
▫ Tumorigenic pigment cell confined to epidermis
▫ Metastasis do not occur
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• Invasive vertical growth phase
▫ Malignant cell consists of a tumorigenic nodule vertically invade dermis.
▫ Metastasis potential
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In vertical growth phase
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Clinical Manifestation
• Gradual darkening of one area of mole
• Change in shape
• Variegation of colour with mixes of brown, dark brown & black
• Radial to vertical growth
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2. Nodular Melanoma
• Epidemiology
▫ Age : middle age
▫ Sex : equal incidence between male and female
▫ Race : all races
▫ Incidence : 15-30 %
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Pathogenesis
• Same site as SSM
▫ Upper back in male
▫ Lower legs in female
• Arise from :
▫ Preexisting nevus
▫ De novo
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Clinical Manifestation
• Skin lesion
▫ Uniformly elevated blueberry like nodule or ulcerated or thick plaque
▫ May become polypoid (resemble a polyp)
▫ Uniformly dark blue, black or thunder-cloud gray.
▫ Surface may be smooth or scaly, eroded or ulcerated
▫ Early lesion are 1-3 cm (may grow bigger)
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Laboratory Examination
• Dermatopathology
• Appear as epithelioid, spindle or small atypical cells
• Show little lateral ( radial ) growth within and below the epidermis and invade vertically into dermis.
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Management
• Surgical excision
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Lentigo Maligna Melanoma
• Age : median age 65
• Sex : equal in male and female
• Race : high in white
• Incidence : 5 % of primary cutaneous melanoma
• Predisposing Factor
• Older population, outdoor occupation ( farmers, sailor, construction worker )
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Pathogenesis
• LM occur on the face, neck & dorsa of forearms or hands.
• Occur almost always in older person with evidence of heavily sun damaged skin ( dermatoheliosis)
• Radial → vertical growth phase
• MIS → invasive melanoma
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Clinical Manifestation
1. Gray area ( indicate focal regression ) & blue area ( indicate dermal pigment )
2. Papule or nodule
3. Other skin changes such as :
▫ Solar keratosis
▫ Freckling
▫ Telangiectasia
▫ Thinning of skin
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Laboratory examination
• Dermatopathology
▫ Increase number of atypical melanocytedistributed in single layer along the basal layer
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Management
• Very early lesion : Imiquimod
• Excised with 1cm beyond the clinically visible lesion
• Sentinel lymph node removal
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Acral Lentiginous Melanoma
• Age : median age 65 years old
• Incidence : 7-9% in whites , 2-8% asians
• Sex : Male: Female 3:1
• Race : ALM is the principal melanoma in the Japanese (50-70%)
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Clinical Manifestation
• Slow growing tumor (2.5 years)
• Appear in volar surface such as palm and sole
• ALM as subungual melanoma appear first in nail bed and involve over a period of 1-2 years.
• In vertical growth phase, nodules appear
• Area of ulceration and nail deformity and shedding of the nail may occur.
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