Doug Schwartzentruber, MD, FACS

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Melanoma
Doug Schwartzentruber, MD, FACS Medical Director,
Center for Cancer Care At Goshen Health
System Clinical Associate Professor of
Surgery, Indiana University School of Medicine
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Melanoma

• Rare 4 of all non-skin cancers
• Incidence 62,480 in US in 2008 (1,130 in
  Indiana)
• Mortality 8,420 in US in 2008 (5,400 M 3,020
  F)
• Survival 5 yrs
• Stage I 93
• Stage II 68
• Stage III 13-69
• Stage IV 10

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ABCDE Rule

• Asymmetry- one half does not match the other
• Border irregularity-edges are blurred or notched
• Color-the color is not the same over entire mole
• Diameter- the mole is wider than ¼ inch or is
  growing
• Evolving the mole is changing in shape, color
  or size

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Asymmetry
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Benign Mole Symmetrical
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Melanoma Asymmetrical
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Melanoma Asymmetrical
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Border
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Benign Mole Even Edges
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Melanoma Uneven Edges
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Color
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Benign Mole One Shade
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Melanoma Two or More Shades
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Diameter
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Benign Mole 6mm or Smaller
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Melanoma Larger than 6mm
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Evolving
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Melanoma, a Mole that Changes
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Subungual Melanoma
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Acral Melanoma
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Risk factors for melanoma
Family history of melanoma. Dysplastic
Nevi. Previous melanoma. Immunosuppressive
therapy. Many ordinary moles (more than
50). Severe, blistering sunburns. Many
freckles. Fair skin, light eyes.
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Diagnosis of Melanoma
Full Thickness Biopsy

• Punch biopsy
• Insicional biopsy
• Excisional biopsy
• NOT by shave biopsy

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Surgical Management of Melanoma 1
Thickness Margin
In-situ 0.5 cm Invasive
lt 1 mm 1 cm 1- 2 mm 1 or 2 cm
2- 4 mm 2 cm gt 4
mm At least 2 cm
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Sentinel Lymph Node (SLN) Biopsy
Technique Inject blue dye and radio-labeled
colloid at primary tumor or excision
site Biopsy blue and "hot" node
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Sentinel Lymph Node (SLN) Biopsy
Melanoma Primary SLN Biopsy lt 1mm No
(Selective) 1-4 mm Yes gt 4mm No
(Selective)
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Surgical Management of Lymph Nodes
Node dissection generally done Clinically ()
nodes (TLND Therapeutic Lymph Node
Dissection) Clinically (-) nodes and SLN (CLND
Completion Lymph Node Dissection) Node
dissection generally not done Clinically (-)
nodes and SLN biopsy NEG
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Elective Lymph Node Dissection
Retrospective studies suggested benefit of ELND
for intermediate thickness primary Four
prospective randomized studies (WHO x 2, Mayo
Clinic and Intergroup) show no overall
benefit of ELND Intergroup study showed benefit
of ELND for subsets of patients Primary
1-2 mm, no tumor ulceration
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Melanoma Staging
Stage Primary
Nodes Distant Mets I
lt 1.0 mm NO
NO 1-2 mm no ulcer II 1-2 mm
ulcer NO NO gt2.0 mm
III Any
YES or NO
In
transit IV Any
Any YES
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Balch CM, J Clin Oncol 193635-3648, 2001
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PET and Melanoma
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PET and MelanomaDetection of Metastases PET vs
CT
CT
PET/CT
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Adjuvant Therapy of Melanoma
Agents Chemotherapy Immunotherapy BCG Vac
cines IFN ? Levamisole Vitamin
A Radiation Limb Perfusion Results No
survival advantage
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Surgical Treatment of Metastatic Melanoma
Review of Published Series Metastatic
Site 5 Yr. Survival Skin, soft tissue,
node 9-61 Lung 0-25 Brain 0-16 Gas
trointestinal 0-19 Coit, et al., Semin Surg
Oncol 9239-245, 1993
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Systemic Therapy of Metastatic Melanoma

Response Chemotherapy Single Agent
15-25 Multi Agent 30-50 High
Dose BMT 40-65 Interferon ?
10-20 Interleukin 2 10-20 Chemo-immunothe
rapy 40-65
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RESPONSE OF PATIENTS WITH METASTATIC CANCER
TREATED USING HIGH-DOSE BOLUS INTERLEUKIN-2
Diagnosis Total CR
PR CR PR

Number of patients () Melanoma 182 12 (7) 16
(9) 28 (15) Renal Cell 227 21 (9) 22 (10) 43
(19) Cancer
Total 409 33 (8) 38 (9) 71 (17)
Patients accrued between Sept. 1985 and Nov.
1996. Follow-up as of March 1, 2001 (median
follow-up 10.1 yrs)
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Metastatic Melanoma Treated With IL-2
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Metastatic Melanoma Treated With IL-2
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Metastatic Melanoma Treated With IL-2
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Melanoma and Pregnancy
Pregnancy does not alter prognosis Recommend
Melanoma patients who are pregnant should be
treated the same as non-pregnant
patients Counsel patients to delay future
pregnancy for 2 years Mackie, et al., Lancet
337653-655, 1991
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Tips for Prevention of Skin Cancer

• Avoid sun exposure between 1100 a.m. and 300
  p.m.
• Wear lightweight clothing covering as much skin
  as possible.
• Wear wide brimmed hat whenever possible
• Wear sunglasses to protect the eyes and sensitive
  skin around the eyes
• Avoid the use of sunlamps and tanning beds

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Tips forSunscreen (Sun block) Application

• Use sunscreen with SPF 15 or higher
• Replace sunscreens on a yearly basis
• Suitable coverage requires the use of 1-2oz of
  sunscreen per application
• Reapply sunscreen every 3 to 4 hours during sun
  exposure
• Reapply sunscreen after leaving the water, even
  if the sunscreen is labeled waterproof.