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Malignant melanoma
melanoma
Malignant melanoma
-malignant tumor arising from melanocytes-tendency to early lymphogenic and haematogenic metastasing
-fast increasing incidence of melanoma in the world
middle Europe 1930: 1-2 patients/ 100 000 persons1960: 5 patients/100 000 1990: 10-14 patients/100 000 2010: 14-16 patients/100 000
Australia : 60 patients/ 100 000 personsAfrica, Asia : 0,1-0,5 patients/ 100 000 persons
-Approx. men=women-54 years:average age of melanoma patient-Arising number of thin melanomas „low-risk“ due to campaigns
Pathogenesis of malignant melanoma
-genetics (FAMMM syndrome, syndrome of dysplastic naevi)
-large congenital naevi, multiple dysplastic naevi
-immunosuppression (HIV, transplantation)
-UV-light
Highest incidence and mortality: men (54 years+)Highest incidence and mortality: men (54 years+)
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Highest incidence and mortality: men (54 years+)Highest incidence and mortality: men (54 years+)
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-FAMMM syndrome(familial atypical multiple mole and melanoma) sy.-Syndrome of dysplastic naevi
Genetics
30-50% melanomas arising in a pigment mole
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Congenital naevi
N. giganteus (5-7 % risk of melanoma)
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Congenital naevi
•small 2 cm•medium-sized 2-20 cm•large -above 20 cm (MM 5-7 %)
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UV-light
-intermittent intensive UV-exposition-chronical UV-exposition(lentigo maligna melanoma, epithelial tumors)-skin fototype (I,II)-sunburns in childhood-frequent vacation (close to equator)
UVA: 320-400 nmUVB: 280-320 nmUVC: 40-280 nm
fototype sunburn pigmentation
I always never
II always sometimes
III sometimes always
IV never always
V dark skin
Distribution of melanomas in men and women
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SSM (superficial spreading melanoma)
-65 % -horizontal growth in the initial phase, later verticalization (small nodules)-relatively good prognosis due to long history
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SSM (superficial spreading melanoma)
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Nodular melanoma
- 20 % -initially smooth surface , later verrucous or ulcerating-short history due to rapid vertical growth-unfavourable prognosis
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Nodular melanoma
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Lentigo maligna melanoma
- 10 % -arising from lentigo maligna (praecancerosis)-face, hands, scalp (sun-exposed areas))-elder people-relatively good prognosis due to long history and location
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UV light
intermittent intensive UV-exposition
chronical UV-exposition lentigo maligna melanoma
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Lentigo maligna melanoma
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Acrolentiginous melanoma
- 5 %
-palms, soles, subungual, oral or genital mucosa -initially smooth surface , later verrucous or ulcerating
-bleeding due to mechanical trauma
-diff. diagnosis: subungual haemorrhage
-unfavourable prognosis
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Acrolentiginous melanoma
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Acrolentiginous melanoma
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Rare forms of melanoma
- 5 %Amelanotic melanoma-difficult diagnostics-often nodular, erodating nodules on extremities-metastases are also amelanotic
Mucosal melanoma
Occult melanoma
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Rare forms of melanoma
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Mucosal melanoma
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Diagnostics
-historyearly phase (rapid growth, change of colour, regression)late phase(bleeding, itching, inflammation, ulceration)
-ABCDE rules
-dermoscopy
-histological examination (never diagnostic incision)
ABCDE rules
asymmetry border colour diameter elevation
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Diagnostics
80 %
92-95 %Picture
Dermoscopy
•pigment network•hyperpigmentation•brown globules•blue-white veil
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Histological examination
Breslow index –exact thickness in mm
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I: tumor cells in epidermisII: tumor cells in str. papillareIII: tumor cells infiltrating upper coriumIV: tumor cells infiltrating entire coriumV: tumor cells infiltrating subcutis
Clark classification
Histological examination
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Histological examination
MelanomaMelanoma cells are in nests and have frequent mitosis
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Therapy
!Excision with safety margin!
Therapy according to the stage
High risk patients: immunotherapy interferon alfa x peptide vaccines
Visceral metastases: chemotherapy Dacarbazin (lung, liver, bones, brain)
Bone and brain metastases: irradiation
Surgery of primary melanoma
Tumor thickness
Safety margin
Tis 0,5 cm
<2 mm 1 cm
>2 mm 2 cm
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Lymph node and skin metastasis
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Skin metastasis
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Sentinel lymph node
•important for prognosis of the patient
•1.draining lymph node
I. affected SLN: radical lymphadenectomy
II. unaffected SLN: no further surgical intervention
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SLN- lymphoscintigraphy
Dosis of 0,4 ml Tc 99 as colloid Gamma camera
Lymphoscintigraphy- dynamics20 min
SLN marked with Tc
Patent blue
• Upper extremity: min. 10-20 min• Lower extremity: min. 30 min
Sentinel lymph node-patent blue
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Sentinel lymph node
I.
II.
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