Brandon Melanoma is a malignant tumor that account for nearly 1.5% of all skin carcinomas.1 It occurs most frequently in white adults, and is seen rarely in dark-skinned ethnicities.1 Melanoma occurs equally in men and women and usually peaks in the 4th to 5th decade in adulthood.1 The most common forms of melanoma are: Superficial Spreading Melanoma (account for 60% to 70%), Nodular Melanoma (30%), and Lentigo (occurs rarely and usually in adults over 70).1 Tumor depth and thickness are two important diagnostic factors.1
Etiology:
Brandon Many of the risk factors for Melanoma are the same as other skin carcinomas (Basal Cell Carcinoma and Squamous Cell Carcinoma). They include:2
Fair skin
History of blistering sun burns
Excessive UV ray exposure
Living closer to the equator or at higher elevations
Having a lot of moles or unusual moles
A family history of Melanoma
Weaken immune system
Signs & Symptoms:
Ashley The signs and symptoms of melanoma are very well documented. Melanomas are known to develop as new moles or alter existing ones. To remember the signs and symptoms of melanoma and aid in early diagnosis, the “ABCDE” acronym is helpful. Asymmetry: Mole differs between one side or the other. 3 Border: Border of the mole is irregular or undistinguishable. 3 Color: Coloration differs throughout mole. 3 Diameter: Increase or decrease in size (Most often and increase to “pea” size). 3 Evolving: The mole has changed over the course of weeks or months. 3
The mole seen below follows all fo the criteria listed above.
Figure 1. Reprinted from National Cancer Institute.3
Diagnostic Procedures:
Ashley The diagnosis of most skin cancers begins with a self-examination. Most patients will notice a mole change colors, borders or become irregular. Once the patient reports the abnormality to their physician, the doctor examines the area and gets an extensive history to determine the likelihood of cancer development. 4 The doctor may also schedule yearly visits to examine your body for the presence or development of moles. The most common questions involve family history and sun exposure. If the doctor suspects the lesion is suspicious, a biopsy is ordered to determine if a malignancy is present. 4
Histology:
Amanuel Histologic sub-types of melanoma include:5
Superficial spreading melanoma [75% of all melanomas]
Epidermal malanocytes
Intraepidermal melaocytes [commonly large cells]
Nodular melanoma [most common in middle aged adults]
Lentigo maligna and maligna melanoma [seen on sun damaged head and neck of elderly people]
Acral lentiginous melanoma [rare and found on acral surfaces]
Mucosal lentiginous melanomas
Lymph node drainage:
When melanomas progress beyond stage II, they spread to nearby lymph nodes.6
Metastatic spread:
Lindsey Melanomas may spread to lymph nodes, lungs, brain, bone, etc.7 Sometimes, these tumors may be found before the melanoma on the skin is even seen.
Grading:
Lindsey If grading is not specified for a given tumor, the following system is commonly used:8 Gx: undetermined grade G1: well differentiated---low grade G2: moderately differentiated---intermediate grade G3: poorly differentiated---high grade G4: undifferentiated---high grade
Staging:
Kevin TX: Primary tumor cannot be assessed. T0: No evidence of primary tumor. Tis: Melanoma in situ (The tumor remains in the epidermis). T1a: Less than or equal to 1.0 mm thick (1.0 mm = 1/25 of an inch), without ulceration and with a mitotic rate of less than 1/mm2. T1b: Less than or equal to 1.0 mm thick. It is ulcerated and/or the mitotic rate is equal to or greater than 1/mm2. T2a: Between 1.01 and 2.0 mm thick without ulceration. T2b: Between 1.01 and 2.0 mm thick with ulceration. T3a: Between 2.01 and 4.0 mm thick without ulceration. T3b: Between 2.01 and 4.0 mm thick with ulceration. T4a: Thicker than 4.0 mm without ulceration. T4b: Thicker than 4.0 mm with ulceration. N categoriesThe possible values for N depend on whether or not a sentinel lymph node biopsy was done. The clinical staging of the lymph nodes, which is done without the sentinel node biopsy, is listed below. NX: Nearby (regional) lymph nodes cannot be assessed. N0: No spread to nearby lymph nodes. N1: Spread to 1 nearby lymph node. N2: Spread to 2 or 3 nearby lymph nodes, OR spread of melanoma to nearby skin or toward a nearby lymph node area (without reaching the lymph nodes). N3: Spread to 4 or more lymph nodes, OR spread to lymph nodes that are clumped together, OR spread of melanoma to nearby skin or toward a lymph node area and into the lymph node(s). Following a lymph node biopsy, the pathologic stage can be determined, in which small letters may be added in some cases: •Any Na (N1a or N2a) in the lymph node(s), but it is so small that it is only seen under the microscope (also known as microscopic spread). •Any Nb (N1b or N2b) in the lymph node(s) and was large enough to be visible on imaging tests or felt by the doctor before it was removed (also known as macroscopic spread). •N2c has spread to very small areas of nearby skin (satellite tumors) or has spread to skin lymphatic channels around the tumor (without reaching the lymph nodes). M categories The M values are: M0: No distant metastasis. M1a: Metastasis to skin, subcutaneous (below the skin) tissue, or lymph nodes in distant parts of the body, with a normal blood LDH level. M1b: Metastasis to the lungs, with a normal blood LDH level. M1c: Metastasis to other organs, OR distant spread to any site along with an elevated blood LDH level. Stage grouping Once the T, N, and M groups have been determined, they are combined to give an overall stage, using Roman numerals I to IV (1 to 4) and sometimes subdivided using capital letters. This process is called stage grouping. In general, patients with lower stage cancers have a better outlook for a cure or long-term survival. Stage 0: Tis, N0, M0: The melanoma is in situ, meaning that it is in the epidermis but has not spread to the dermis (lower layer). Stage IA: T1a, N0, M0: Less than 1.0 mm in thickness. It is not ulcerated and has a mitotic rate of less than 1/mm2. It has not been found in lymph nodes or distant organs. Stage IB: T1b or T2a, N0, M0: Less than 1.0 mm in thickness and is ulcerated or has a mitotic rate of at least 1/mm2, OR it is between 1.01 and 2.0 mm and is not ulcerated. It has not been found in lymph nodes or distant organs. Stage IIA: T2b or T3a, N0, M0: Between 1.01 mm and 2.0 mm in thickness and is ulcerated, OR it is between 2.01 and 4.0 mm and is not ulcerated. It has not been found in lymph nodes or distant organs. Stage IIB: T3b or T4a, N0, M0: Between 2.01 mm and 4.0 mm in thickness and is ulcerated, OR it is thicker than 4.0 mm and is not ulcerated. It has not been found in lymph nodes or distant organs. Stage IIC: T4b, N0, M0: Thicker than 4.0 mm and is ulcerated. It has not been found in lymph nodes or distant organs. Stage IIIA: T1a to T4a, N1a or N2a, M0: Can be of any thickness, but it is not ulcerated. It has spread to 1 to 3 lymph nodes near the affected skin area, but the nodes are not enlarged and the melanoma is found only when they are viewed under the microscope. There is no distant spread. Stage IIIB One of the following applies: T1b to T4b, N1a or N2a, M0: Can be of any thickness and is ulcerated. It has spread to 1 to 3 lymph nodes near the affected skin area, but the nodes are not enlarged and the melanoma is found only when they are viewed under the microscope. There is no distant spread. T1a to T4a, N1b or N2b, M0: Can be of any thickness, but it is not ulcerated. It has spread to 1 to 3 lymph nodes near the affected skin area. The nodes are enlarged because of the melanoma. There is no distant spread. T1a to T4a, N2c, M0: Can be of any thickness, but it is not ulcerated. It has spread to small areas of nearby skin or lymphatic channels around the original tumor, but the nodes do not contain melanoma. There is no distant spread. Stage IIIC: One of the following applies: T1b to T4b, N1b or N2b, M0: Can be of any thickness and is ulcerated. It has spread to 1 to 3 lymph nodes near the affected skin area. The nodes are enlarged because of the melanoma. There is no distant spread. T1b to T4b, N2c, M0: Can be of any thickness and is ulcerated. It has spread to small areas of nearby skin or lymphatic channels around the original tumor, but the nodes do not contain melanoma. There is no distant spread. Any T, N3, M0: Can be of any thickness and may or may not be ulcerated. It has spread to 4 or more nearby lymph nodes, OR to nearby lymph nodes that are clumped together, OR it has spread to nearby skin or lymphatic channels around the original tumor and to nearby lymph nodes. The nodes are enlarged because of the melanoma. There is no distant spread. Stage IV: Any T, any N, M1(a, b, or c): Spread beyond the original area of skin and nearby lymph nodes to other organs like the lung, liver, or brain, or to distant areas of the skin, subcutaneous tissue, or distant lymph nodes. Neither spread to nearby lymph nodes nor thickness is considered in this stage, but typically the melanoma is thick and has also spread to the lymph nodes.9
Radiation side effects:
Kevin Side effects of radiation are dependent on where the radiation is aimed. Some include:* Erythema of the treated area is the earliest side effect
Dermatitis dependent of the dosage and energy used
Dry desquamation
Moist desquamation
Burning and itching symptoms
Radiation necrosis (usually in higher fractional doses)
Hair loss10
Prognosis:
Jenn The following survival rates are based on nearly 60,000 patients who were part of the 2008 AJCC Melanoma Staging Database.11
Stage IA: The 5-year survival rate is around 97%. The 10-year survival is around 95%. Stage IB: The 5-year survival rate is around 92%. The 10-year survival is around 86%. Stage IIA: The 5-year survival rate is around 81%. The 10-year survival is around 67%. Stage IIB: The 5-year survival rate is around 70%. The 10-year survival is around 57%. Stage IIC: The 5-year survival rate is around 53%. The 10-year survival is around 40%. Stage IIIA: The 5-year survival rate is around 78%. The 10-year survival is around 68%. Stage IIIB: The 5-year survival rate is around 59%. The 10-year survival is around 43%. Stage IIIC: The 5-year survival rate is around 40%. The 10-year survival is around 24%. Stage IV:The 5-year survival rate is about 15% to 20%. The 10-year survival is about 10% to 15%. The outlook is better if the spread is only to distant parts of the skin or distant lymph nodes rather than to other organs, and if the blood level of lactate dehydrogenase (LDH) is normal.
Treatments:
Jenn Melanoma is generally treated with surgery. Radiation therapy has also played a role in treating melanomas. Malignant melanoma cells are sensitive to ionizing radiation but show a wide shoulder under the cell survival curve, suggesting that higher than conventional doses per fraction are required for cell kill. Skin or mucosal melanomas involving the oral cavity, vagina, and anus can be treated with radiation, with doses of 60 to 70 Gy in 2 to 3 Gy fractions. Radiation therapy is a primary treatment modality for metastatic disease involving lung, lymph nodes, bone, eyes and central nervous system.12
TD 5/5:
Rachel
The TD 5/5 for skin is 55 Gy.13 Telangiectasia and fibrosis are seen with doses to skin of over 45 Gy and are likely with doses over 65 Gy. Skin necrosis is the most severe late effect and is seen with doses over 55 Gy.
References:
Chao K, Perez C, Bardy L. Radiation Oncology Management Decisions. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins. 2002. 115
Melanoma is a malignant tumor that account for nearly 1.5% of all skin carcinomas.1 It occurs most frequently in white adults, and is seen rarely in dark-skinned ethnicities.1 Melanoma occurs equally in men and women and usually peaks in the 4th to 5th decade in adulthood.1 The most common forms of melanoma are: Superficial Spreading Melanoma (account for 60% to 70%), Nodular Melanoma (30%), and Lentigo (occurs rarely and usually in adults over 70).1 Tumor depth and thickness are two important diagnostic factors.1
Many of the risk factors for Melanoma are the same as other skin carcinomas (Basal Cell Carcinoma and Squamous Cell Carcinoma). They include:2
The signs and symptoms of melanoma are very well documented. Melanomas are known to develop as new moles or alter existing ones. To remember the signs and symptoms of melanoma and aid in early diagnosis, the “ABCDE” acronym is helpful.
Asymmetry: Mole differs between one side or the other. 3
Border: Border of the mole is irregular or undistinguishable. 3
Color: Coloration differs throughout mole. 3
Diameter: Increase or decrease in size (Most often and increase to “pea” size). 3
Evolving: The mole has changed over the course of weeks or months. 3
The mole seen below follows all fo the criteria listed above.
The diagnosis of most skin cancers begins with a self-examination. Most patients will notice a mole change colors, borders or become irregular. Once the patient reports the abnormality to their physician, the doctor examines the area and gets an extensive history to determine the likelihood of cancer development. 4 The doctor may also schedule yearly visits to examine your body for the presence or development of moles. The most common questions involve family history and sun exposure. If the doctor suspects the lesion is suspicious, a biopsy is ordered to determine if a malignancy is present. 4
Histologic sub-types of melanoma include:5
Melanomas may spread to lymph nodes, lungs, brain, bone, etc.7 Sometimes, these tumors may be found before the melanoma on the skin is even seen.
If grading is not specified for a given tumor, the following system is commonly used:8
Gx: undetermined grade
G1: well differentiated---low grade
G2: moderately differentiated---intermediate grade
G3: poorly differentiated---high grade
G4: undifferentiated---high grade
TX: Primary tumor cannot be assessed.
T0: No evidence of primary tumor.
Tis: Melanoma in situ (The tumor remains in the epidermis).
T1a: Less than or equal to 1.0 mm thick (1.0 mm = 1/25 of an inch), without ulceration and with a mitotic rate of less than 1/mm2.
T1b: Less than or equal to 1.0 mm thick. It is ulcerated and/or the mitotic rate is equal to or greater than 1/mm2.
T2a: Between 1.01 and 2.0 mm thick without ulceration.
T2b: Between 1.01 and 2.0 mm thick with ulceration.
T3a: Between 2.01 and 4.0 mm thick without ulceration.
T3b: Between 2.01 and 4.0 mm thick with ulceration.
T4a: Thicker than 4.0 mm without ulceration.
T4b: Thicker than 4.0 mm with ulceration.
N categoriesThe possible values for N depend on whether or not a sentinel lymph node biopsy was done.
The clinical staging of the lymph nodes, which is done without the sentinel node biopsy, is listed below.
NX: Nearby (regional) lymph nodes cannot be assessed.
N0: No spread to nearby lymph nodes.
N1: Spread to 1 nearby lymph node.
N2: Spread to 2 or 3 nearby lymph nodes, OR spread of melanoma to nearby skin or toward a nearby lymph node area (without reaching the lymph nodes).
N3: Spread to 4 or more lymph nodes, OR spread to lymph nodes that are clumped together, OR spread of melanoma to nearby skin or toward a lymph node area and into the lymph node(s).
Following a lymph node biopsy, the pathologic stage can be determined, in which small letters may be added in some cases:
•Any Na (N1a or N2a) in the lymph node(s), but it is so small that it is only seen under the microscope (also known as microscopic spread).
•Any Nb (N1b or N2b) in the lymph node(s) and was large enough to be visible on imaging tests or felt by the doctor before it was removed (also known as macroscopic spread).
•N2c has spread to very small areas of nearby skin (satellite tumors) or has spread to skin lymphatic channels around the tumor (without reaching the lymph nodes).
M categories The M values are:
M0: No distant metastasis.
M1a: Metastasis to skin, subcutaneous (below the skin) tissue, or lymph nodes in distant parts of the body, with a normal blood LDH level.
M1b: Metastasis to the lungs, with a normal blood LDH level.
M1c: Metastasis to other organs, OR distant spread to any site along with an elevated blood LDH level.
Stage grouping Once the T, N, and M groups have been determined, they are combined to give an overall stage, using Roman numerals I to IV (1 to 4) and sometimes subdivided using capital letters. This process is called stage grouping. In general, patients with lower stage cancers have a better outlook for a cure or long-term survival.
Stage 0: Tis, N0, M0: The melanoma is in situ, meaning that it is in the epidermis but has not spread to the dermis (lower layer).
Stage IA: T1a, N0, M0: Less than 1.0 mm in thickness. It is not ulcerated and has a mitotic rate of less than 1/mm2. It has not been found in lymph nodes or distant organs.
Stage IB: T1b or T2a, N0, M0: Less than 1.0 mm in thickness and is ulcerated or has a mitotic rate of at least 1/mm2, OR it is between 1.01 and 2.0 mm and is not ulcerated. It has not been found in lymph nodes or distant organs.
Stage IIA: T2b or T3a, N0, M0: Between 1.01 mm and 2.0 mm in thickness and is ulcerated, OR it is between 2.01 and 4.0 mm and is not ulcerated. It has not been found in lymph nodes or distant organs.
Stage IIB: T3b or T4a, N0, M0: Between 2.01 mm and 4.0 mm in thickness and is ulcerated, OR it is thicker than 4.0 mm and is not ulcerated. It has not been found in lymph nodes or distant organs.
Stage IIC: T4b, N0, M0: Thicker than 4.0 mm and is ulcerated. It has not been found in lymph nodes or distant organs.
Stage IIIA: T1a to T4a, N1a or N2a, M0: Can be of any thickness, but it is not ulcerated. It has spread to 1 to 3 lymph nodes near the affected skin area, but the nodes are not enlarged and the melanoma is found only when they are viewed under the microscope. There is no distant spread.
Stage IIIB One of the following applies:
T1b to T4b, N1a or N2a, M0: Can be of any thickness and is ulcerated. It has spread to 1 to 3 lymph nodes near the affected skin area, but the nodes are not enlarged and the melanoma is found only when they are viewed under the microscope. There is no distant spread.
T1a to T4a, N1b or N2b, M0: Can be of any thickness, but it is not ulcerated. It has spread to 1 to 3 lymph nodes near the affected skin area. The nodes are enlarged because of the melanoma. There is no distant spread.
T1a to T4a, N2c, M0: Can be of any thickness, but it is not ulcerated. It has spread to small areas of nearby skin or lymphatic channels around the original tumor, but the nodes do not contain melanoma. There is no distant spread.
Stage IIIC: One of the following applies:
T1b to T4b, N1b or N2b, M0: Can be of any thickness and is ulcerated. It has spread to 1 to 3 lymph nodes near the affected skin area. The nodes are enlarged because of the melanoma. There is no distant spread.
T1b to T4b, N2c, M0: Can be of any thickness and is ulcerated. It has spread to small areas of nearby skin or lymphatic channels around the original tumor, but the nodes do not contain melanoma. There is no distant spread.
Any T, N3, M0: Can be of any thickness and may or may not be ulcerated. It has spread to 4 or more nearby lymph nodes, OR to nearby lymph nodes that are clumped together, OR it has spread to nearby skin or lymphatic channels around the original tumor and to nearby lymph nodes. The nodes are enlarged because of the melanoma. There is no distant spread.
Stage IV: Any T, any N, M1(a, b, or c): Spread beyond the original area of skin and nearby lymph nodes to other organs like the lung, liver, or brain, or to distant areas of the skin, subcutaneous tissue, or distant lymph nodes. Neither spread to nearby lymph nodes nor thickness is considered in this stage, but typically the melanoma is thick and has also spread to the lymph nodes.9
Side effects of radiation are dependent on where the radiation is aimed. Some include:* Erythema of the treated area is the earliest side effect
The following survival rates are based on nearly 60,000 patients who were part of the 2008 AJCC Melanoma Staging Database.11
Stage IA: The 5-year survival rate is around 97%. The 10-year survival is around 95%.
Stage IB: The 5-year survival rate is around 92%. The 10-year survival is around 86%.
Stage IIA: The 5-year survival rate is around 81%. The 10-year survival is around 67%.
Stage IIB: The 5-year survival rate is around 70%. The 10-year survival is around 57%.
Stage IIC: The 5-year survival rate is around 53%. The 10-year survival is around 40%.
Stage IIIA: The 5-year survival rate is around 78%. The 10-year survival is around 68%.
Stage IIIB: The 5-year survival rate is around 59%. The 10-year survival is around 43%.
Stage IIIC: The 5-year survival rate is around 40%. The 10-year survival is around 24%.
Stage IV:The 5-year survival rate is about 15% to 20%. The 10-year survival is about 10% to 15%. The outlook is better if the spread is only to distant parts of the skin or distant lymph nodes rather than to other organs, and if the blood level of lactate dehydrogenase (LDH) is normal.
Melanoma is generally treated with surgery. Radiation therapy has also played a role in treating melanomas. Malignant melanoma cells are sensitive to ionizing radiation but show a wide shoulder under the cell survival curve, suggesting that higher than conventional doses per fraction are required for cell kill. Skin or mucosal melanomas involving the oral cavity, vagina, and anus can be treated with radiation, with doses of 60 to 70 Gy in 2 to 3 Gy fractions. Radiation therapy is a primary treatment modality for metastatic disease involving lung, lymph nodes, bone, eyes and central nervous system.12
The TD 5/5 for skin is 55 Gy.13 Telangiectasia and fibrosis are seen with doses to skin of over 45 Gy and are likely with doses over 65 Gy. Skin necrosis is the most severe late effect and is seen with doses over 55 Gy.
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