A Tan to Die For?

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A Tan to Die For?

• Dan Magrill
• Taz Singh
• Laura Tincknell

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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 NV.
• PMH - No THREAD. L Testicular lump 18/12 - under
  observation.

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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...

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History and Examination cont...

• Respiratory - No cough, wheeze, S.O.B,
  haemoptysis...
• GI - No NV, 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...

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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

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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.

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Presentation of a disease

• In Incidence
• A Age
• Surgeons Sex
• Gown Geography
• Physicians Predisposing factors
• Might Macro/Micro Pathology
• Make Management
• Progress Prognosis

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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

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Age

• Superficial Spreading and Nodular Malignant
  Melanoma - 20-60 year olds
• Lentigo Malignant Melanoma - gt60y.

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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)

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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

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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

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Macro/Micro Pathology 1

• Superficial Spreading Malignant Melanoma
• 50 of UK cases, especially female
• Commonest in Lower Leg
• Macular Tumour with Variable Pigmentation

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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

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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

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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

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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

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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

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Differential Diagnosis

• Benign melanocytic naevus
• Seborrhoeic wart
• Haemangioma
• Dermatofibroma
• Pigmented Basal Cell Carcinoma
• Benign Lentigo

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Management 1

• Surgical Excision
• If lt1mm, use a 1cm clearance margin
• If gt1mm, 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)

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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
  gt1.5mm thick

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Prognosis

• Related to tumour depth
• 5 year survival
• lt1mm 95-100
• 1-2mm 80-96
• 2.1-4mm 60-75
• gt4mm 50

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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