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mel·a·no·ma(mel'ă-nō'mă), Avoid the redundant phrase malignant melanoma.
melanoma/mel·a·no·ma/ (mel″ah-no´mah) a tumor arising from the melanocytic system of the skin and other organs; used alone, it refers to malignant m..
melanomaA tumour that comprises 1–3% of all new cancers (18,000/year) and causes 6500 deaths/year (US), most age 30–50; melanoma is increasing at ± 7%/year, and now affects 9/105 (primarily the head and neck) in men and 12/105 (primarily legs) in women; it is rare but more aggressive in children.
Giant congential melanocytic nevus, dysplastic nevus, xeroderma pigmentosum, immunodeficiency, moles with persistent pigment changes (especially > age 15), large or irregularly pigmented lesions, familial moles, congenital moles, Caucasian (12-fold greater risk than Black), previous melanoma, melanoma in 1st-degree relative, immunosuppression, photosensitivity, increased sun exposure.
Site of metastasis
Liver, lung, intestine, pancreas, adrenal, heart, kidney, brain, spleen, thyroid.
Wide excision; chemo- and radiation are essentially useless.
Local recurrence common; many metastasise; 5-year survival reflects stage when diagnosed.
Poor prognostic factors
Large size, paranasal/nasopharyngeal location, vascular invasion, high mitotic activity, marked cellular pleomorphism, distant metastases.
Stages of melanoma
▪ Stage I—Confined to epidermis and/or upper dermis, and measures ≤ 1.5-mm thick.
▪ Stage II—1.5-mm to 4-mm thick; spread to lower dermis but not beyond or to adjacent lymph nodes.
▪ Stage III—Any of the following:
– > 4-mm thick;
– Spread beyond the skin;
– Satellite lesions within 2 cms of the original tumour; or
– Spread to nearby lymph nodes or satellite lesions between original and regional lymph nodes.
▪ Stage IV—Metastases to other organs or to lymph nodes far from the original lesion.
Types of melanoma
Acral lentiginous melanoma
A rare, flat, palmoplantar or subungual lesion more common in non-whites; average 5-year survival < 50%; unrelated to actinic exposure, but possibly related to ectopic pigmentation.
Rare, poorly differentiated, and occurs in those with a previous pigmented melanoma; since the Fontana-Masson stain is rarely positive in amelanotic melanoma, special studies are necessary, including immunoperoxidase staining with antibodies to the S-100 antigen and ultrastructural examination for presence of premelanosomes.
Comprises 10% of melanomas; affects those > age 60; appears as flat, indolent lesions on face, arising from a premalignant freckle with greater than 90% 5-year survival; aetiologically linked to prolonged actinic exposure.
15% of cases; similar clinically to superficial spreading melanoma; 50% average 5-year survival.
1/3 of lentigo maligna (Hutchinson’s freckle) progress to malignant melanoma after 10–15 years.
Superficial spreading melanoma
70% of cases; affects ages 30 to 60, especially female in lower legs or trunk, as a flat lesion (radial growth phase) that may be present for months to years; average 5-year survival 75%; aetiologically linked to recreational actinic exposure.
Thin melanoma (Stage-I cutaneous melanoma)
A lesion measuring < 1 cm in diameter; virtually 100% survival.
melanomaMalignant melanoma Dermatology A tumor which comprises 1-3% of all new cancers–18,000/yr, causes 6500 deaths/yr–US, most age 30–50; the incidence of melanoma is ↑ at ± 7%/yr, and now affects 9/105, primarily head & neck in ♂ and 12/105, primarily the legs in ♀; melanoma is rare, but more aggressive in chidren Risk factors Giant congential melanocytic nevus, dysplastic nevus, xeroderma pigmentosum, immunodeficiency, moles with persistent pigment changes–especially > age 15, large or irregularly pigmented lesions, familial moles, congenital moles; white–12-fold greater risk than blacks, previous melanoma, melanoma in 1st-degree relative, immunosuppression, photosensitivity, ↑ sun exposure; ocular melanomas may not ↑ melanoma risk Site of metastasis Liver, lung, intestine, pancreas, adrenal, heart, kidney, brain, spleen, thyroid. See Acral lentiginous melanoma, Amelanotic melanoma, Congenital melanoma, Dysplastic nevus syndrome, Lentigo maligna melanoma, Nodular melanoma, Ocular melanoma, Premalignant melanoma, Pseudomelanoma, Radial growth phase melanoma, Superficial spreading melanoma, Thin melanoma, Vertical growth phase melanoma, Vertical growth phase melanoma.
melanoma(mel?a-no'ma) [ melano- + -oma]
The likelihood of long-term survival depends on the depth of the lesion (thicker lesions are more hazardous), whether it is ulcerated, the histological type (nodular and acral lentiginous melanomas are more dangerous than superficial spreading or lentigo malignant melanomas), the patient's age (older patients do more poorly), and gender (men tend to have a worse prognosis than women). See: ABCD; skin cancer
Excessive exposure to ultraviolet light, esp. sunlight, contributes to the development of melanoma, as does a family history of the disease. It is more common in fair-skinned than dark-skinned people and more common in people who have many moles on the skin than in those who have few. Total body skin examinations should be performed periodically on high-risk patients. On average, consistent screening identifies melanomas at an earlier stage (when they are thinner, or localized, rather than after they have spread) than those found on routine examination.
People spending considerable time outside should wear protective clothing to shield against ultraviolet radiation and use sunscreens (at least SPF15) on exposed skin.
Common melanoma sites are the back, shoulders, head and neck (men), the legs (women), and the backs. A skin biopsy and histologic examination can distinguish malignant melanoma from a benign nevus, seborrheic keratosis, or pigmented basal cell epithelioma; it also determines tumor thickness and tumor stage. Staging is based on the TNM system and Clark’s levels system, which classifies tumor progression according to skin layer penetration. Once diagnosed, patients need physical, psychological, and social assessment and care. Treatment options should be explained.
Melanomas are treated with surgery to remove the primary cancer and adjuvant therapies (chemotherapy and biotherapy) to reduce the risk of metastasis. Closure of a wide resection around an excised tumor may require skin grafting. Vaccines have been developed against melanoma; they appear to improve prognosis in affected patients.
After surgery, dressings are inspected for drainage and signs of infection, and the patient is taught about prevention and signs to report. The patient should be taught that close follow-up care will be needed to detect recurrences at an early stage, and that this must continue for years (13% of recurrences develop more than 5 yrs after the primary lesion). When therapy fails, the patient and family will need referrals for palliative (hospice) care and may also require social services and spiritual care.
in situ melanoma
The lesion should be removed by an experienced surgeon.
Patients diagnosed with melanoma in situ need careful follow-up examinations in case the tumor recurs, spreads, or is associated with other skin cancers.
melanomaAny benign or malignant tumour of MELANOCYTES. See also MALIGNANT MELANOMA.
melanomaa highly malignant tumour of melanin-producing cells, usually occurring in the skin. Excessive exposure to UV radiation in strong sunlight is a contributory factor.
melanomamalignant neoplasm of melanocytes; capable of widespread metastasis (see Table 1)
cutaneous melanoma malignant epidermal tumour strongly associated (in fair-skinned or red-haired individuals) with prolonged childhood exposure to sunlight; a melanocytic naevus may undergo malignant change to form a melanoma; up to one-third of melanomas present as non-pigmented skin lesions (Table 2; see ABCDE; sign, Hutchinson's; Table 3 and Figure 1)
subungual melanoma melanotic or amelanotic malignant tumour arising from epidermal melanocytes within proximal nail fold
|Lentigo malignant melanoma||Slow-growing flat lesion, often affecting facial skin in the elderly|
Irregular border, slowly extending
May develop nodular centre, ulcerate and spread aggressively
|Superficial spreading melanoma||May affect any skin area, especially in Caucasians (male back, female leg)|
Irregular raised border, slowly extending
Central area may become pale and appear to 'resolve' (which designates that the lesion is invading underlying tissues)
|Nodular melanoma||May affect any skin, but especially the lower limbs and trunk|
Many lesions are amelanotic ± pigmented collar
Grows rapidly and bleeds easily
May be misdiagnosed as a vascular lesion
|Acral lentiginous melanoma||Tends to present in black and oriental skin|
Presents initially as a flat freckle-like lesion that extends and becomes nodular
|Subungual melanoma||Melanoma involving the nail unit|
May be difficult to distinguish from benign melonychia or subungual haematoma
Tends to affect proximal nail area and eponychium, and spreads distally
|I||Lesion confined to epidermis (i.e. in situ)|
|II||Epidermal lesion has just invaded into upper dermis|
|III||Epidermal lesion has significantly invaded upper dermis|
|IV||Epidermal lesion has invaded as far as deeper reticular dermis|
|V||Epidermal lesion has invaded through dermis into subcuticular tissues|
The greater the depth of lesion penetration, the more liable it is to undergo metastasis.
|Seborrhoeic keratoses (senile or seborrhoeic wart; basal cell papilloma)||Incidence increases with advancing age|
Location: trunk, but also affect leg and foot
Cellular involvement: epidermal cells
Progression: start as small lesions which increase in size and degree of pigmentation over time
Edge: distinct edge which may overhang surrounding skin
Pigmentation: variable colour; homogeneous pigmentation
Surface: warty; horny cysts
Differential diagnosis: verrucae; hyperkeratosis
Treatment: liquid nitrogen; curettage
|Bowen's disease (intraepidermal carcinoma in situ)||Location: sun-exposed skin - face, neck, legs, dorsum of foot|
Progression: slowly enlarging reddish, scaly patch; 1:20 lesions may progress to a squamous cell carcinoma
Cellular involvement: the entire epidermis is replaced by abnormal cells (atypical nuclei and mitosis patterns) but the basement membrane is normal
Edge: irregular, clearly demarcated margin
Surface: scaly or crusted
Differential diagnosis: psoriasis
Treatment: early stages: 5-fluorouracil; late stages: liquid nitrogen or curettage
|Basal cell carcinoma (BCC) (rodent ulcer; basal cell epithelioma)||Commonest skin tumour in Caucasians; incidence increases with advancing age; rarely metastatic|
Location: sun-exposed skin: commonest on the face; rare on the foot
Progression: initially small lesion which gradually extends over months to years; it may crust over and appear to heal, but crust comes away to reveal the underlying lesion
Cellular involvement: basal-layer epidermal cells bud downwards toward the dermis to form dermal palisades
Edge: raised/rolled nodular (pearly) border
Surface: domed ± central eroding and extending ulcer
Differential diagnosis: Bowen's disease, squamous cell carcinoma, melanoma, vascular lesions
Treatment: excision and biopsy; liquid nitrogen, radiation therapy
|Squamous cell carcinoma (SCC) (cutaneous cell carcinoma)||Second most common cell tumour; locally destructive and may metastasize via the lymphatics|
Aetiology: immune-suppressed patients; albinos; impaired DNA repair mechanisms; skin contaminants (soot, tar, mineral oils, hydrocarbons); as the end development of Bowen's disease or actinic keratoses; chronic irritation (such as in a long-standing leg ulcer); repeated exposure to radiation (ultraviolet, X-rays; radiant heat)
Location: any area of skin, but rare on the foot (a variant, verrucous carcinoma, is only found on the foot - see below)
Progression: begins as a reddish plaque mimicking dermatitis or eczema, becoming indurated
Edges: irregular and raised
Surface: nodular and/or irregular, ragged, sloughy, ulcer; oozing
Treatment: wide excision and biopsy; lymphadenectomy and radiation therapy if there is associated lymphatic spread
|Verrucous carcinoma of the foot (epithelioma; carcinoma cingulatum)||Location: at any skin site; predilection for plantar skin|
Progression: initially resembles verruca plantaris; slowly progressive to form a nodular lesion and later a soggy, foul-smelling ulcer with sinuses somewhat remote from the main lesion
Cellular involvement: obviously malignant epidermal cells invade the dermis
Treatment: as for SCC
choroidal melanoma The most common primary malignant tumour in the eye in adults. It appears under ophthalmoscopic examination as a pigmented, elevated mass, usually brown in colour and sometimes with orange pigment (lipofuscin). The tumour may cause a decrease in vision or brief 'balls of light' moving cross the visual field, or be asymptomatic, depending on its size or location. The condition is typically unilateral. Differential diagnosis with retinal detachment or choroidal naevus is essential. Treatment may include radiotherapy or photocoagulation, or enucleation if the melanoma is large and vision irreversibly lost. Syn. malignant melanoma of the choroid.
iris melanoma A pigmented lesion, which is easily seen on the surface of the iris. It alters the colour of the iris and may distort the shape of the pupil. A dilated episcleral vessel running towards the tumour may be present. There may be a localized cataract where the tumour is in contact with the lens and secondary glaucoma may develop if the tumour has spread to the angle of the anterior chamber. The tumour arises from the iris stroma and is composed of epitheloid or spindle cells, or a mixture of both. It is almost always unilateral and most commonly found in white patients with light irides. It is thought to originate from a previous pigmented naevus. If the tumour is found to enlarge it will usually be excised surgically. (Fig. M7) See iris naevus.
uveal melanoma Tumour which may be located in the choroid, the ciliary body or the iris. Choroidal melanomas make up about 85% of the total, ciliary body about 10% and iris about 5%. Although uveal melanomas can occur at any age, the majority of patients are beyond the age of 40 years. Uveal melanomas can metastasize, especially choroidal melanomas. Diagnosis is best achieved with a B-scan ultrasound examination. The patient must be referred to an ocular oncologist without delay. See ultrasonography.