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Melanoma

Melanoma. Almost 30% of all melanomas arise in the head and neckWidespread use of sunscreen has not lowered the incidence.Incidence is increasing almost 5% per yearApproximately 47,000 new cases in 2001. Predisposing Factors. Sun ExposureAge, frequency, severity of exposure may play a roleSunsc

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Melanoma

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    1. Melanoma Alan L. Cowan Anna M. Pou

    2. Melanoma Almost 30% of all melanomas arise in the head and neck Widespread use of sunscreen has not lowered the incidence. Incidence is increasing almost 5% per year Approximately 47,000 new cases in 2001

    3. Predisposing Factors Sun Exposure Age, frequency, severity of exposure may play a role Sunscreen use may not be protective Familial Melanoma / DNS Family members have almost 50% chance of developing melanoma Lesions may be multiple and in sun shielded areas Xeroderma Pigmentosa Predisposes to several types of skin cancer Skin malignancies often appear by age 10

    4. Sunlight UVB (280-320nm) Causes direct DNA damage Originally thought to be primary factor Blocked by current sunscreens UVA (320-400nm) Causes indirect DNA damage via free radicals Some now consider as more important than UVB Sunscreen has little UVA protection

    5. Types of Melanoma Superficial Spreading Most common Cells atypical but uniform in appearance Nodular Early invasion due to vertical growth Acral Lentiginous Appears on palms and soles Histology shows heavily pigmented dendritic processes in the basal layer

    6. Types of Melanoma Desmoplastic May lack pigment Peri-neural invasion is classic Histologic exam may show “school of fish” appearance Lentigo Maligna Melanoma May remain in-situ for decades Can spread along hair follicles Mucosal Often lack melanin Conventional staging system does not apply Site of lesion corresponds to prognosis Nasal cavity best prognosis, 31% at 5-yrs Paranasal sinuses worst prognosis, 0% at 5-yrs

    7. Diagnosis History Family History Sun exposure Bleeding, pain Physical ABCD Histology H&E S-100, HMB-45

    8. Biopsy Excisional Recommended for small lesions Margins of 2mm Incisional For larger lesions Does not alter draining lymphatics Punch Same as incisional Shave Contraindicated Needle Contraindicated

    9. Clark staging Based upon histologic level of invasion Level I – Epidermis only (in situ) Level II – Invades the papillary dermis, but not to the papillary-reticular interface Level III – Invades to the papillary-reticular interface, but not into the reticular dermis Level IV – Into the reticular dermis Level V – Into subcutaneous tissue

    10. Breslow staging Based upon absolute depth of invasion Stage I – < 0.75 mm Stage II – 0.76 – 1.5 mm Stage III – 1.51 – 4.0 mm Stage IV - > 4.0 mm

    11. AJCC staging

    12. AJCC staging

    13. AJCC staging

    14. Prognosis by AJCC stage Stage I < 0.75 – 96 % 0.75 – 1.5 – 87 % Stage II 1.5 – 2.49 – 75 % 2.5 – 3.99 – 66 % > 4.0 – 47 % Stage III One node 45 % Two nodes < 20 % Stage IV 8 – 10 % Percentages are five year survival except stage IV lesions which represent one year survival

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