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Melanoma

Melanoma is a malignant tumour arising from melanocytes in the skin

Third most common skin cancer in the UK Accounts for more cancer deaths than all other skin cancers combined The incidence is increasing worldwide in white populations- highest incidence is observed in Australia Incidence of melanoma increases with age Incidence is increasing in all age-groups and is predicted to continue to rise – although it is diagnosed more in older people It is thought that 1-2 % of melanomas are due to inheritance of melanoma susceptibility genes ( CKDN2A mutations ) In the US melanoma is a rare disease – affecting only 22.1 out of 100,000 people , however it is also very deadly accounting for 75 % of skin cancer deaths though it only accounts for 4 % of skin cancers

Seven point checklist-Major features of the lesion → 2 points each

○ change in size
○ irregular shape or border
○ irregular contour
 Minor features of the lesion → 1 point each

○ Largest diametre 7 mm or more
○ inflammation
○ oozing or crusting of the lesion
○ change in sensation ( including itch )

3 point or more → lesion suspicious
However if strong concerns about cancer any one feature is adequate to promt a USC referral

What happens Melanoma arises from melanocytes- responsible for pigment production Genetic and environmental factors are implicated in aetiology Cancer arises due to accumulation of genetic mutations leading to misregulation of cellular pathways Majority of melanomas arise from somatic mutations acquired in later life A melanoma which develops in healthy skin is said to arise de novo Some lesions are considered to be precursor lesions of melanoma – for e.g
○ common acquired nevus
○ dysplastic nevus
○ congenital nevus
○ cellular blue nevus Pathogenesis ( melanogenesis ) is a subject of ongoing research Two growth phases are recognised
○ radial – malignant cells grow in a radial fashion in the epidermis
○ vertical growth – malignant cells invade the dermis and develop the ability to metastsize

ABCD lesion system –
ABCD Check list identifies early signs of melanoma that are useful for the diagnosis


 A → asymmetry B → border irregularity C → colour variegation or changes ( atleast 2 diff colours) D → diameter greater than 6 mm. E → elevated / evolutionary changes in
○ colour
○ size
○ symmetry
○ surface charecteristics and 
○ symptoms

 F → firm G → growing progressively for 1 month or longer


Risk factors-Family history of melanoma →1st degree family member Previous h/o melanoma Skin lesions such as :

○ high density of freckles or a tendency to freckle in sun
○ a large number of normal moles →risk rises with the number of common moles
○ five or more atypical moles
 ♦ Atypical moles →ill-defined or irregular border ; irregular pigmentation ;dia > 5 mm; erythema ; accentuated skin markings
○ actinic lentigines → flat brown , skin lesions associated with acute and chronic sun exposure
○ giant congenital melanocytic naevus
 Pale skin ( type 1 and 2 ) that does not tan easily and burns ; light coloured eyes Red or light- coloured hair Unusually high sun exposure Affluence Increasing age Female sex


Assessment –Examine in good light
 Use the 7 point checklist / ABCDE
 Thorough history ( taking into account risk factors )
 Complete skin examination
○ ugly duckling sign → lesion which stands out from crowd
 Lymph node palpation ( eg cervical , axillary and inguinal )
○ may disseminate through lymphatics and haematogenously can involve any node basin
 Dermatoscopy ( also called Dermoscopy )
○ if trained to do so
○ may more accurately distinguish betwenn benign and malignant lesions
○ device shines polarized light on the skin and magnified skin lesions with or without a fluid interface
 Consider baseline blood tests
○ LFT ( ↑ AlkPo4 – may indicate metastasis to bobe , liver)
 AST / ALT ↑ may suggest liver metastasis
○ ALbumin/ protein- indicate gen health
○ U/E- baseline ( chemotherapy can be nephrotoxic )
○ LDH – marked elevation may suggest distant metastasis and a poor prognosis


Superficial spreading melanoma –Most commonly seen subtype ( about 80 % of all melanomas ) Proliferation of atypical melanocytes singly and in nests at all levels within the epidermis Asymmetrical pigmented lesion with variable pigmentation and some time irregular outline Can be crusted and presents in different shades of brown , black , red , blue or white Pts may have noted growth , a change in sensation and / or colour , crusting , bleeding or inflammation of lesion Most frequently on calves of women and back of men Duration of the symptoms vary from a few months to several years Presents from 4th to 5th decade

Nodular melanoma –Second most common subtype First observed as a black or blue nodular growth Shape and pigmentation usually more uniform than that of superficial spreading melanoma Develops often over a period of few months into a dome shaped nodule- may ulcerate and bleed easily Commonly on legs and trunks 5th or 6th decade of life Grows faster than other melanomas →easily misdiagnosed

Lentigo maligna melanoma –Similar to normal lentigo but has colour variegation and irregular margins Grows slowly over yrs Sun damaged skin → head and neck of older patients Only type- has a clearly recognised and often lengthy pre-invasive ( in situ ) lesion called – Lentigo maligna before progressing

Acral lentignous melanoma –Commonly found on the palms of the hands and soles of the feet or around the big toe nail Flat pigmented area , slowly increasing in size becoming ↑ ingly irregular in colour May be covered with reactive callus ( corn ) if on sole →may develop a nodule with ulceration and bleeding Occurs in all ethnic groups

Amelanotic melanoma –Usually have no or very little colour→ flesh coloured pink or erythematous nodule Difficult to identify Any rapidly growing nodule → should be in the DD A small focus of pigments usually present

Lesions suggestive of melanoma –Lesion scoring 3 points or > on 7 pt checklist
( If strong suspicion cancer any one feature is adequate for referral ) New nodule which are pigmented or vascular in appearance Nail changes

Including nodular and amelanotic melanoma.Any doubt about the lesion Persistently slowly evolving unresponsive skin condition with an uncertain diagnosis and melanoma is a possibility Biopsy confirms melanoma

Giant congenital pigmented naevi – risk ↑↑ if 20 cm or more Family hx – 3 or more cases →refer clinical geneticist or specialised dermatology for counselline Family hx 2 cases- will also benefit More than 100 normal moles Multiple atypical moles 



Regularity of colour , surface and border → suggest benign nature Rapid growth over days rather than weeks → suggest pyogenic granuloma Stuck on appearance with keratotic plug on the surface → suggest seborrhoeic keratosis Dimpling if b/l pressure applied → suggest dermatofibroma Child presenting with a pigmented lesion

LINKS AND RESOURCES

PATIENT INFORMATION

A complete patient information package from the British Association of Dermatologists http://www.bad.org.uk/for-the-public/skin-cancer/melanoma-leaflets

National Cancer Institute – Melanoma treatment https://www.cancer.gov/types/skin/patient/melanoma-treatment-pdq

Cancer Org on Melanoma – covering all aspects from diagnosis to treatment https://www.cancer.org/cancer/melanoma-skin-cancer.html

NHS on melanoma https://www.nhs.uk/conditions/melanoma-skin-cancer/

Patient education from Skin Cancer Foundation https://www.skincancer.org/skin-cancer-information/melanoma/melanoma-warning-signs-and-images/

Melanoma Patients Australia -consider for those who have been diagnosed recently 24 page guide https://www.petermac.org/sites/default/files/media-uploads/A%20guide%20to%20understanding%20melanoma%20A%20starting%20point%20for%20people%20in%20their%20journey%20with%20melanoma.pdf

A complete resource for patients with a family h/o melanoma from GenoMEL- the melanoma Genetics Consortium http://genomel.org/info-for-patients/having-a-family-history-of-melanoma/ 

Melanoma charities 
Melanoma Focus https://melanomafocus.com/
Melanoma UK https://www.melanomauk.org.uk/
Melanoma Fund https://www.melanoma-fund.co.uk/
Melanoma International Foundation http://melanomainternational.org/web-resources/#.Xjcvrmj7Rxl

Ocular Melanoma https://www.ocumeluk.org/

 

INFORMATION FOR CLINICIANS

A well-drafted easy to use guide for GPs from Cancer Research UK– if you are lucky enough to have a fixed room for yourself consider getting a printout and sticking on the wall https://www.cancerresearchuk.org/sites/default/files/gp_june_2017_-_sun_and_skin_cancer_guide.pdf 

For images check Derm Net NZ https://dermnetnz.org/topics/melanoma/

A large library of image from Dermnet -a very useful reference http://www.dermnet.com/images/Malignant-Melanoma

7-point checklist- an easy reference from Dermlite https://dermlite.com/pages/7-point-checklist

Another page from Dermascopy Org on 7 point checklist http://www.dermoscopy.org/consensus/2d.asp

RCGP dermatology toolkit in association with Primary Care Dermatology Society https://www.rcgp.org.uk/dermatologytoolkit

A quick melanoma referral guide from National cancer Control Programme Ireland https://www.hse.ie/eng/services/list/5/cancer/news/national-melanoma-gp-referral-guidelines.pdf

A similar quick referral guide on pigmented skin lesions from NHS Scotland http://www.cancerreferral.scot.nhs.uk/media/1014/suspicious-pigmented-lesions-and-changing-melanocytic-naevi.pdf

NICE- Melanoma assessment and management 876 page guideline https://www.nice.org.uk/guidance/ng14/evidence/appendix-h-pdf-250314591

ESMO CLINICAL PRACTICE GUIDELINES: MELANOMA https://www.esmo.org/guidelines/melanoma

Revised U.K. guidelines for the management of cutaneous
melanoma 2010 https://www.bad.org.uk/library-media%5Cdocuments%5CMelanoma_2010.pdf
J.R. Marsden, J.A. Newton-Bishop,* L. Burrows, M. Cook, P.G. Corrie,§ N.H. Cox,– M.E. Gore,** P. Lorigan,
R. MacKie, P. Nathan,§§ H. Peach,–– B. Powell*** and C. Walker

Guidelines of care for the management of primary cutaneous melanomaSwetter, Susan M. et al.Journal of the American Academy of Dermatology, Volume 80, Issue 1, 208 – 250 https://www.jaad.org/article/S0190-9622(18)32588-X/fulltext

References Melanoma : summary of NICE guidance BMJ 2015;351:h3708 Melanoma and Cutaneous Malignant Neoplasms Sabiston Textbook of Surgery Charles W.Kimbrough et al Twentieth edition Problematic pigmented lesions: approach to diagnosis SL Edwards , K Blessing J Clin Pathol 2000;53:409-418 Treatment of Skin Disease : Comprehensive Therapeutic Strategies 4th Edition 2014 Malignant Melanoma Melanoma Types Cancer Research UK accessed via http://www.cancerresearchuk.org/about-cancer/melanoma Suspected cancer : recognition and referral NICE guidelines NG 12 June 2015 Malignant melanoma BMJ 2009;339:b3078 Fast facts Skin Cancer Karen L agnew et al Health Press SIGN 146.Cutaneous melanoma A national clinical guideline January 2017 Melanoma and pigmented lesions CKS NHS Prevention , diagnosis , referral and management of melanoma of the skin Royal College of Physicians Concise guidelines 2007 Malignant Melanoma Clinical Presentation Medscape Winston W Tan et al Nov 2016 Cutaneous Malignant Melanoma : A Primary Care Perspetive Am Fam Physician.2012 Jan 15;85(2) 161-168

Malignant melanoma  a pictorial view https://www.ums.ac.uk/umj083/083(2)103.pdf
Lauren E. Davis, Sara C. Shalin & Alan J. Tackett (2019) Current state of melanoma diagnosis and treatment, Cancer Biology & Therapy, 20:11, 1366-1379, DOI: 10.1080/15384047.2019.1640032
SIGN Guideline via https://www.sign.ac.uk/assets/sign146.pdf
NICE USC guidelines via https://www.nice.org.uk/guidance/ng12/chapter/1-Recommendations-organised-by-site-of-cancer#skin-cancers
Malignant melanoma NCBI Bookshelf https://www.ncbi.nlm.nih.gov/books/NBK470409/

 

 

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