Melanoma

A: Asymmetry (melanoma lesion more likely to be asymmetric) B: Border irregularity (melanoma more likely to have irregular borders) C: Color (melanoma more likely to be very dark black or blue and have variation in color than a benign mole which is more often uniform in color and light tan or brown) D: Diameter (mole < 6 mm in diameter usually benign)(most that are 6mm or greater need to be evaluated). In addition to the ABCD’s other signs should be observed.[5] || II. Tumor present in but does not fill and expand papillary dermis III. Tumor fills and expands papillary dermis IV. Tumor invades into reticular dermis V. Tumor invades subcutis || 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. 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: 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. 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. [].
 * **Epidemiolgy:** || Approximately 76,250 men and women will be diagnosed with melanoma of the skin, and an estimated 9,180 men and women will die from the disease. The mean age from 2005-2009 is 61 years old. Whites had the highest incidence at 31.6 per 100,000 men and 19.9 per 100,000 women, whereas blacks had the lowest incidence of 1.1 per 100,000 men and 0.9 per 100,000 women. 1.99% of men and women born today will be diagnosed with melanoma of the skin at some point during their lifetime based on rates from 2007-2009. [1] ||
 * **Etiology:** || * Genetics
 * UV radiation
 * Sunburn
 * Chemicals
 * Viruses
 * Changing mole
 * Dysplastic nevi in familial melanoma
 * More then 50 nevi, 2 mm or greater in diameter
 * Family member with melanoma
 * Previous history of melanoma
 * Sporadic dysplastic nevi
 * Immunosuppression
 * Sun sensitivity
 * History of acute, severe, blistering sunburns
 * Freckling [2] ||
 * **Signs & Symptoms:** || Nearly 70% of all melanomas occur form a change in a preexisting nevus (mole).[5]the accepted rules of early detection of melanomas can be summed up in the “ABCD’s”
 * Change in color. (Red, white, blue/black)
 * Change in surface. (scaly, flaky, bleeding or moles that don’t heal)
 * Change in texture. (hard or lumpy moles)
 * Change in surrounding skin. (skin near mole that pigmentation is changing)
 * Change in sensation. (painful or tender mole)
 * Change in previously normal skin. ||
 * **Diagnostic Procedures:** || Self-inspection is the earliest form of detections and if any of the factors from the ABCD or irregular mole observations are noticed than a clinical evaluation should be done.
 * Physical exam focusing on changes in normal skin appearance
 * Notation of (mole, freckle or blemish) size, diameter and symmetry
 * Depth of invasion of tumor must be defined with a “dermatoscope” or other “epiluminescence microscopy” (ELM).
 * Once the diagnosis of advanced melanoma has been established the course of action can include.[5]
 * Full physical exam to establish other sites
 * Motor skill assessment to detect brain involvement
 * Chest x-ray for lung involvement
 * Liver function test for liver involvement
 * CBC count
 * Alkaline phosphatase levers and bone scan
 * Biopsy of site
 * Surgical excision or resection
 * Also (PET, CT, MR) if involvement has been established. ||
 * **Histology:** || Plasma cells are 2-3 times larger than typical lymphocytes; they have eccentric nuclei that are smooth (round or oval) in contour with clumped chromatin and have a perinuclear halo or pale zone (see the image below).[6] The cytoplasm is basophilic.[6]
 * **Lymph node drainage:** || A search of the literature does not demonstrate lymph node drainage playing a role in this disease.[6] ||
 * **Metastatic spread:** || Plasma cells circulate through the blood and lymph systems, multiple myeloma can appear in a localized area or may be disseminated anywhere in the body.[6] Therefore, because of its nature, multiple myeloma does not metastasize to any specific organ.[6] ||
 * **Grading:** || Depth and thickness are the greatest prognostic indicators and are rated on anatomic levels called “Clark Levels”. [4] I. Intraepidermal tumor only
 * **Staging:** || ** 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.
 * 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).
 * 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 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:
 * 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. ||
 * **Radiation side effects:** || 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 loss [3] ||
 * **Prognosis:** || The prognosis for melanoma is directly related to the thickness of the melanoma (measured by the pathologist). Some other factors include depth of penetration, ulceration, and mitotic activity. It is important to remove the entire melanoma at its earliest stage to reduce the chance of metastatic spread. [7] ||
 * **Treatments:** || [[image:uwlmedicaldosimetry2012/melanomapic.jpg]]

Treatments for melanoma are surgery, radiation therapy, and chemotherapy. The dose for radiation is 60-70 Gy, in 2-3 Gy per fraction. The fields should include the entire tumor with a 5 cm margin. [8] []. || || 2. Drugs, Diseases & Procedures. Medscape. http://emedicine.medscape.com/article/. Accessed June 27, 2012. 3. Hows Melanoma staged?. Available at: []. Accessed on July 4th 2012. 4. Protocol for Examination of Specimens from Patients With Squamous cell Carcinoma of the Skin. Available at: __[|http://www.cap.org]__. Accessed on July 5th, 2012. 5. Washington, Charles, and Dennis Leaver. Principles and Practices of Radiation Therapy.St. Louis,Missouri: Mosby Elsevier, 2010. 6.Seiter, K.Multiple Myeloma Workup. Medscape.July 2, 2012.Available at: [|http://emedicine.medscape.com/article/204369-workup#aw2aab6b5c15]. Accessed on: July 5, 2012. 7. Melanoma. Emedicine health. Available at: [] . Accessed on July 2, 2012. 8. Chao KS, Perez CA, Brady LW. Radiation Oncology: Management Decisions. Philadelphia, PA: Lippincott Williams & Wilkins; 2002 9. Emami B, Lyman J, Brown A, et al. Tolerance of normal tissue to therapeutic irradiation. //Int J Radiat Oncol Biol Phys. // 1991;109-122. ||
 * **TD 5/5:** || The TD 5/5 for a skin dose is: [9]
 * **References:** || 1. SEER Stat Fact Sheets: Melanoma of the Skin. Surveillance Epidemiology and End Results (SEER). []. Accessed July 2, 2012.

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