Cutaneous Melanoma

Posted by e-Medical PPT Thursday, August 8, 2013
A xx year old male presents to your office with a complaint of a right upper extremity skin lesion that has changed in size, shape and color. He is afraid that it might be melanoma. How would you approach and evaluate this patient?

Melanoma
Melanocytes - originate from neural crest cells - found along basement membrane at the dermoepidermal junction - exposure to carcinogenic stimuli result in malignant transformation and melanoma
•Accounts for 4 – 5% of all skin cancers, but causes majority of deaths
•Eighth most common cancer in the United States
•68,130 new cases; 8700 deaths in US (2010)

Epidemiology - 20x more common in white individuals, especially those of Celtic ancestry; less in Asian and black population - anatomic distribution varies among gender - men: trunk, head and neck - women: lower extremities - median age at presentation: 45-55yrs

Etiology - exposure to sunlight - UV radiation (UVA and UVB) - UVA: deeper level of penetration leading to dermal connective tissue damage - UVB: induces effects of sunburn, increases melanin production

Risk Factors - fair complexion, severe sunburns, intermittent doses of radiation (sun bathing, tanning beds) - xeroderma pigmentosum, family history of melanoma, history of non-melanoma skin cancer, dysplastic nevi syndrome - Aging: related to either exposure to carcinogens (UV radiation) or the decreasing ability of individual cells to repair DNA damage - Precursor Lesions: congenital nevi, dysplastic nevi, spitz nevi

Xeroderma Pigmentosum - autosomal recessive - inability to repair DNA damage caused by UV radiation - incidence 1 in 250,000 - increased risk for skin cancers; melanoma and SCC most common cause of death - symptoms: severe sun burn to minimal sun exposure, freckles, solar keratoses, painfully sensitive eyes to sun exposure - poor prognosis, less than 40% survive beyond 20 yrs of age

Giant Congenital Nevi - rare, occurs in 1 in 20,000 newborns - increased risk of melanoma within nevi - lifetime risk 5-8% - require regular examination throughout life

Dysplastic Nevi (DN) - large (6-15mm), flat pigmented lesion - indistinct margins, variable color - may occur sporadically or in a familial pattern

Dysplastic Nevi (DN) - DN syndrome ( BK mole syndrome, FAMMM syndrome): multiple nevi >100, mutation CDKN2A gene, chromosome 9, leads to unstable p53; penetrance for melanoma ranges 52-98% - unclear consensus in management; can excise all lesions - surveillance mandatory; complete skin examination every 3-6 months, monthly self-examination
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