Download Malignant melanoma

Case 15
A 39 years - old Thai male
Chief complaint:
Asymptomatic brownish plaque at left shoulder
Present illness:
He has been presenting with asymptomatic brownish
plaque at left shoulder for 1 year. This lesion gradually increase
in size. He has no systemic symptom.
Past history:
No underlying disease.
Family history:
No one in his family has lesion like him.
Physical examination
General appearance : not pale , no jaundice
HEENT:
normal , no lymphadenopathy
Heart:
normal
Lung:
clear
Abdomen:
soft , no organomegaly
Inguinal LN can’t palpable
Skin:
solitary brownish plaque with small satellite lesion
diameter 1.5 cm. at left shoulder
Fig 15.1
Fig 15.2
Skin excisional biopsy
Histology
:
there is a proliferation of atypical
melanocytes with large pleomorphic nuclei both single
and in nest at all layer of the epidermis
Pathological diagnosis: malignant melanoma measuring
approximate 2 mm in depth
Management : Wide excision (2 cm. from the edge
of lesion and excise down to underlying muscle)
Pathological finding : No residual tumor
Labolatory investigation
CXR (AP)
: normal
CT chest & abdomen:
small pulmonary nodule at
posterior RUL, uncertain nature?
sputum AFB x 3 days – negative
Follow up film after 7 months showed no progression
Plan : follow up size of the nodule
CT brain:
no nodular,no plaque like
intraparenchymal enhancement noted.
Bone scan:
normal
leptomeningeal
or
Diagnosis: malignant melanoma stage IB (T2a,N0,M0)
5 year survival rate:
between 90–95%
doctor may order tests such as a brain MRI, a CT scan,
or a PET scan. If the sentinel node(s) is identified, then
it will be biopsied along with a wide excision of
melanoma and 1 to 2 cm of surrounding skin. This may
be smaller if the melanoma located on the face.
Because it is not certain what treatment is best, no
further treatment is one option.
Follow up :
Complete history and physical exam should be done every
3 to 6 months for 3 years, then every 4 to 12 months for 2
years, and then yearly.
Chest x-ray , complete blood count and blood LDH level
every 6 to 12 months, although this is optional.
Presenter:
Piyawadee Chitasombuti
Consultant:
Natta Rajatanavin
Discussion
Cutaneous melanoma is an increasingly common,
enigmatic, and potentially lethal malignancy of melanocytes. The
salient challenge for clinicians is to detect and excise melanoma
in its earliest stage, as tumor thickness remains the most
important prognostic indicator for primary cutaneous melanoma.
Early diagnosis and surgical excision of in situ or early invasive
melanoma are curative in most patients. Despite advances in
chemotherapy and immunotherapy, the success in the treatment
of advanced melanoma remains limited, and the prognosis of
metastasic disease is guarded.
In this case, melanoma is stage IB ( melanoma is thicker
than 1 mm and lymph nodes are not enlarged) . The only tests
that might be done are a blood LDH level and a chest x-ray.
Because stage II melanomas may spread to other organs, the
References
1. Balch CM et al. Prognostic factors analysis of 17,600 patients:
Validation of the American Joint Committee on Cancer
melanoma staging system. J Clin Oncol 2001;19 :3622
2. Rigel DS : Melanoma update: 2001. Skin Cancer found J
2001;19:13
3. Ahmedin J et al. Cancer statistics,2002. CA Cancer J Clin
2002;52:2
4. Detail Guide: Skin Cancer – Melanoma: How is melanoma
Staging
:
American
Cancer
Society,
Inc,2004
:www.cancer.org/docroot/cri/content/
cri_2_4_3x_how_is_melanoma_staged_50.asp
5. Melanoma
treatment
guidelines
for
patients
:
NCCN
www.nccn.org/patients/patient_gls/_english/_melanoma/inde
x.htm