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LIVE BLOG: Melanoma Update

 
The following Live Blog is highlights from the “Melanoma Update” lecture with Dr. Firas Hougeir at the 11th Annual SDPA Fall Conference in Atlanta, Georgia.
 
 
Common Nevus Epidemiology
Sometimes nevus will grow as the bodies grow.  A growing mole in a child is less of a warning sign, than if a new nevi is shown in someone over 30.
 
Congenital Nevus 
+ They are not all melanomas but they do increase the risk of melanoma in the patient.
+ All CNN should be documented at birth
+ Atypical appearing CNN should be considered for prophylactic 
 
Dysplastic Nevi 
+ Atypical appearing melanocytic tumor characterized by intra-epidermal 
+ 1 in 4 adults have dysplastic nevi
+ Can appear as large moles at the end of 1st decade
+ Occur regardless of how the patient interacts with sun
 
Appearance 
1. “Fried egg” look
2. Multiple hues
3. Irregular outline
4. Relatively large size
 
Treatment 
1. Monthly self-exam
2. Photographs (…if taken with caution to exact angle every time)
3. Photoprotection: sun protection, sun avoidant 
4. Prophylactic excision for lesions difficult to monitor
5. Excise all atypical or changing lesions!
 
Prognosis 
+ Development of melanoma
Study of 14 melanoma-prone family members: 40 new melanomas developed in pts w DN:
These pts have 58% probability to develop MM from 20-59 years and 100% by 76 years
Pts with no hx have 7-70 fold chance
 
Malignant Melanoma 
+ Malignancy of melanocytes-skin, eyes, ears, GI tracts
+ Lifetime risk in 1 in 71 Americans
+ 4% of all skin cancers are Melanomas: causes 75% of skin cancer deaths
 
Pathology 
+ Not well understood
+ Can be found on parts of the body that have never been sun-exposed
+ Blistering sunburns are also a cause
+ Over 50% believed to develop nevi
+ Changing moles
 
Melanoma behavioral factors
1. Sunburns: increase MM with number and severity of sunburns
2. Solar exposure during childhood: rates those who immigrated to Australia before 10yo
 
MM Genetic Factors 
With a history of two first-degree relatives, melanoma increases risk; talk to your kids, get them checked.
 
Risks Factors of Melanoma
+ Some arise from nevi, both acquired and congenital
+ The more moles, the higher risk
+ Family history of melanoma
+ Freckles on the upper back
+ Three or more blistering sunburns prior to age 20
+ Actinic keratoses 
 
Stats of Melanoma Patients
Race: primarily white
Sex: more often male
Age: median age 53 years, most common cancer in women 25-29 years and second to breast cancer in women aged 30-40
40% of female melanomas are found below the waist
 
SUBTYPES
 
Superficial Spreading Melanoma
70% of all melanomas
Light-skinned people
Frequently on legs for women, upper back in men
Usually 4th, 5th decades
 
Nodular Melanoma 
Second most common type 15-30%
Found on trunk, head, neck
Sometimes look like ticks 
 
Acral Lentiginous Melanoma
More common type in darker skinned people
Thought to be more aggressive and associated with poorer prognosis 
Subungual melanoma: mainly involve the big toe or thumb
 
Lentigo Maligna Melanoma
Less Common
Mainly in population 65yo or older
Slow moving, you have time to biopsy
Hard to clear, as they are much larger than what you see
 
How Do We Detect Melanomas?
No single feature or clinical sign is diagnostic
Trust yourself when does it “doesn’t look right”
ABCDEs of melanoma
Epiluminescnce microscopy
Just take a Biopsy
“When it doubt, cut it out”
 
Management of Melanoma
History
Total body skin & lymph node examination
Surgical therapy
GME, baseline lab tests, LDH, CXR
Extensive diagnostic tests, (CT, MRI) usually not indicated
 
Lymph Node Evaluation
Find a hospital that does a lot sentinel lymph node biopsies
Refer patients here
 
How to Treat Stage IV Melanoma
Chemotherapy
Immunotherapy
Targeted immunotherapy
Biochemotherapy
Ipilimumab
Adjuvant Therapy
Vemurafenib: Extends life from 9-12 months
Hair loss, weight loss, fast growing KAs
Dabrafenib
FDA Approved May 2013
Tramentinib
FDA Approved May 2013
Combination therapy granted priority review
 
More on Ipilimumab
FDA Approved 2011
Anti CTLA-4 Drug
Leads to increase T-cell activation and proliferation and possible increase of anti-tumor response
2013 European Cancer Congress: survival up to 10 years more in responders
IF YOU REACT WELL, (2% death rate), YOU CAN SURVIVE UP TO 10 YEARS
 
 
Follow-up after Treatment
Monthly self-exams
History 
Do a full body exam with lymph node exam, liver and abdominal palpation in needed (guided by history)
Review of System: double vision, bone pain, weight loss, abdominal pain (Explain that questions are related to finding metastasis so they answer well)
 
 
[image by Yumi Hori]