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A Tan to Die For?

A Tan to Die For?. Dan Magrill Taz Singh Laura Tincknell. Mr. RB History and Examination. Background - 53 yrs, male, unemployed PC - RIF pain

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A Tan to Die For?

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  1. A Tan to Die For? Dan Magrill Taz Singh Laura Tincknell

  2. Mr. RB History and Examination • Background - 53 yrs, male, unemployed • PC - RIF pain • HPC - RIF pain for 1/12, radiating to the back. Loss of appetite, weight loss, tiredness, indigestion. Loose bowels 1/52, no blood or mucus. No N+V. • PMH - No THREAD. L Testicular lump 18/12 - under observation.

  3. History and Examination cont... • FH - Paternal Grandfather - Bowel Ca. Father - Diverticulitis. • SH - Unmarried, living alone and unemployed. Smoking 20+/day. Social drinker. • SE: • CVS - No chest pain, palpitations, breathlessness, orthopnoea, collapse, nocturnal dyspnoea...

  4. History and Examination cont... • Respiratory - No cough, wheeze, S.O.B, haemoptysis... • GI - No N+V, rectal bleeding. But had indigestion, abdo pain, loose bowels, loss of appetite and weight loss... • GU - No dysuria, frequency, haematuria, loin pain... • Neurological - No headaches, dizziness, fits, collapse, weakness...

  5. History and Examination cont • O/E - Anxious, thin. T-37.5C, Pulse-regular, 75 bpm, BP 120/60 mmHg. O2 Sats- 97% • CVS : Unremarkable • Resp: Unremarkable • Neuro: Unremarkable • GI: Abdomen distended. Large firm mass in whole of abdomen apart from LIF which was tender on palpation. Liver percussed out to 35cm. BS present. PR-NAD

  6. Plan • USS: showing multiple liver metastases. Biopsy - melanoma. • Ix to find primary: colonoscopy, CXR, ENT and opthalmology. • Opthalmology report: R eye, smooth melanotic mass in anterior chamber. • Management: Palliative Chemotherapy.

  7. Presentation of a disease • In Incidence • A Age • Surgeon’s Sex • Gown Geography • Physicians Predisposing factors • Might Macro/Micro Pathology • Make Management • Progress Prognosis

  8. Incidence • UK incidence of 10 / 100 000 (per year) • Rising by 7% every Year • Least common of the “Big Three”, but highest mortality. • Over last 20 years, incidence risen by over 80%

  9. Age • Superficial Spreading and Nodular Malignant Melanoma - 20-60 year olds • Lentigo Malignant Melanoma - >60y.

  10. Sex • In the UK, women are affected twice as often as men • In Men, the commonest site is the back • In Women it is the Lower Leg (50%)

  11. Geography • The worldwide incidence is proportional to the Geographic Latitude • Caucasians living closest to equator at highest risk • This suggests an effect of UV radiation • People living outside their indigenous climate are at risk

  12. Predisposing Factors • Fair Skin • Red Hair • Living close to Equator • Freckles • Exposure to the Sun • Melanocytic Naevus (found in 30%) • Genetics - 5% of Pt have Family History

  13. Macro/Micro Pathology 1 • Superficial Spreading Malignant Melanoma • 50% of UK cases, especially female • Commonest in Lower Leg • Macular Tumour with Variable Pigmentation

  14. Macro/Micro Pathology 2 • Nodular Malignant Melanoma • Seen in 25% of UK cases, especially Male • Commonest site is the Trunk • Pigmented Nodule • Grows rapidly and can Ulcerate

  15. Macro/Micro Pathology 3 • Lentigo Malignant Melanoma • 15% of UK cases • Malignant melanoma growing in long standing Lentigo Maligna • These arise form sun damaged skin • Often in elderly, especially who have worked outside for many years

  16. Macro/Micro Pathology 4 • Acral Lentiginous Malignant Melanoma • 10% of UK cases • Commonest form in Mongoloids • Tumour affects Palms, Soles and Nail Beds • Often diagnosed late - poor prognosis

  17. Staging • Local Staging assessed using the BRESLOW method • Measured mm between granular cell layer and deepest identifiable melanoma cell • Metastasis are uncommon if confined to epidermis

  18. Diagnosis • The following changes in a Naevus or Pigmented lesion • Size, usually a recent increase • Shape, irregular in outline • Colour, variation - darker or lighter • Inflammation, especially at edge • Crusting, may ooze or bleed • Itch

  19. Differential Diagnosis • Benign melanocytic naevus • Seborrhoeic wart • Haemangioma • Dermatofibroma • Pigmented Basal Cell Carcinoma • Benign Lentigo

  20. Management 1 • Surgical Excision • If <1mm, use a 1cm clearance margin • If >1mm, need a 1-2cm clearance • As this is quite a large area a skin graft may be indicated • Regular follow up to detect recurrence • Local • Lymphatic, regional or distant • Blood Bourne - to distant sites (eg Liver)

  21. Management 2 • Elective Lymph node dissection and Sentinel node biopsy not recommended as routine. • Radiotherapy of limited use • Interferon-alfa may increase survival if tumour >1.5mm thick

  22. Prognosis • Related to tumour depth • 5 year survival: • <1mm 95-100% • 1-2mm 80-96% • 2.1-4mm 60-75% • >4mm 50%

  23. Prevention and Public Education • If caught early have good prognosis • Public should be encouraged to visit doctor early if changing pigmented lesion • Sun exposure should be discouraged • Especially if fair skinned or with multiple melanocytic naevi

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