NONMALIGNANT MELANOCYTIC AND NEVOMELANOCYTIC NEVUS (NMN)

Some are ordinary moles, some are premalignant Moles in family chances are you also have moles

Compound nevus Intradermal nevus larger Histology of NMN

NMM and NMN Importance: because of their intimate histogenic relationship to cutaneous melanoma In 18-85% of pts hx of preexisting pigmented lesion at the site of primary cutaneous melanoma may be elicited o Previous history of sunburn Therefore, since there is a relationship between melanoma arising from preexisting NMN, it is important that clinicians be able to distinguish those at risk and those not at risk Histologic Classification I. Junctional nevus II. Intradermal nevus III. Compound nevus Nevomelanocytic Nevus Aka common acquired nevomelanoytic nevus Defined as collection of nevus cells present in the epidermis, dermis, or both areas in pigmented lesions of the skin Appear after the first 6-12 months of life Enlarge with body growth Regress slowly with age
Of 345 normal European whites aged 3 weeks to 99 years average mole count per person numbered 15 with a mean of 1st decade 4 2nd decade 18 3rd decade 29 9th decade 2

Changes in NMN, which may be physiologic 1. Pregnancy change color, growth 2. Puberty 3. Systemic corticosteroids 4. Sun exposure may darken the nevi 5. Blistering diseases some develop blisters, some disappear Treatment of NMN Benign neglect may be left alone Excision o Guidelines for Excision a. Cosmetic removal b. Continual irritation c. Hidden sites d. Atypical appearance e. Atypical evolution f. High risk lesions

Course and Prognosis of NMN Harmless and stable May be used for identifying yourself and others Read on Basal Cell Ca and Squamous Cell Ca (this is from Andrews Diseases of the Skin) Basal Cell Carcinoma
BCC is the most common cancer in the US, Australia, New Zealand, and many other countries with a largely white, fair-skinned population with the opportunity to expose their skin to sunlight. Intermittent intense sun exposure, as identified by prior sunburns; radiation therapy; a positive family history of BCC; immunosuppression; a fair complexion, especially red hair; and easy sunburning (skin types I or II); and blistering sunburns in childhood are risk factors for the development of BCC.

Etiology of NMN Size and frequency tend to aggregate in families Postulated as hamartomas originating from defective melanoblasts in the neural crest and very likely have a genetic basis Junctional nevus flat, found in plantar areas, (+) potential for malignant transformation

Squamous Cell Carcinoma

SCC is the second most common form of skin cancer. Most cases of SCC of the skin are induced by UVR. Chronic, long-term sun exposure is the major risk factor and areas which have had such exposure (the face, scalp, neck, and dorsal hands) are favored locations.

MALIGNANT MELANOMA (MM)

It is the leading fatal illness arising in skin Represents 2% of cancer by incidence and 1-2% of cancer deaths Occurs chiefly during productive years Rare in early childhood

Dr. Tom Dulley going up to a hut, slipped and fell from bamboo stairs. He had a bump but he did not have it checked. Several years after, it was diagnosed as malignant melanoma.
5-year Survival Rate 1940 1975 1983

40% 67% 85%

Family history of melanoma: 8-12% increased likelihood P16 mutation Nevi - Melanocytic nevi, dysplastic nevi, changing mole, congenital nevus History of prior melanoma Immunosuppression Gender and hormonal factors - Melanomas are rare before puberty - Females survive longer than males at least for Stages I and II

Epidemiology Affects sexes equally 1:1 Survival rate favors females Incidence ratio (White vs. Black) is 6-7x Less common in Orientals than Whites Traumatic solar exposure (sunburn) early in life risk factor Site Distribution A. Whites vs. Blacks Whites: widely over the body Blacks: palms, soles, nail bed, mucus membranes B. Males vs. Females M: back sparing of lower legs, buttocks and genitals F: lower legs and back, sparing of bra area, abdomen, buttocks, genitalia Distribution Risk Factors for Cutaneous Melanoma Pigmentary Characteristics - Blue eyes, blonde, fair or red hair, light complexion Response to sun exposure - Freckling tendency (red haired, green eyed), inability to tan, tendency to sunburn - History of sunburn as a child Upper socioeconomic status the poor dont have time to go to the beach. The rich people go to the spa, beach in Palawan or Boracay

Precursor Lesions of MM 1. Lentigo maligna 2. Congenital melanocytic nevi 3. Dysplastic nevi (architectural and cytologic atypia 4. Acral and mucosal lentiginous melanocytic proliferation Congenital melanocytic nevus start small then spread Nevus in the eye area

Giant hairy nevus in trunk. Sometimes they degenerate on one area good sign because it will not undergo malignant change Malignant melanoma may arise from the junctional component of nevus cell nevus

b. Horizontal growth can still excise d. Very little horizontal growth, always invade downward to blood vessels spread easily Four Varieties of Melanoma 1. Lentigo maligna melanoma elderly with extensive actinic damage 2. Superficial spreading 70% of all melanoma 3. Acral lentiginous melanoma most common among Blacks 4. Nodular melanoma lacks radial growth; progress rapidly to metastatic disease Lentigo maligna flat lesions, with different colors

 Superficial spreading lighter in color, irregular borders, different colors Nodular rounded, not typical nodule, border is irregular Acral lentiginous palms, soles, nail Clinical Changes in Appearance of New Moles that Warrant a Biopsy A- asymmetry B- Border irregularity C- Color variegation (blue, black, brown, pink, white) D- Large diameter >6mm E- Elevation and enlargement Lentigo Maligna Melanoma Best prognosis Enlarging, irregularly pigmented nodule within the preexisting pigmented patch Favor sun-exposed areas especially face and arms Evolves from precancerous lentigo maligna or Hutchinsons freckle More frequent in women Superficial Spreading Melanoma Slow progression Elevated, haphazard arrangements of color (black, brown, blue, erythematous) Irregular areas of depigmentation Common on lower legs of women; backs of males Acral Lentiginous Melanoma Rare Occurs on palms and soles, and beneath nails Progressively enlarges with variation of colors Nodular Melanoma No radial growth Begin as darkly pigmented nodules often round with a smooth, welldefined border Occurs on any skin surface Course of Malignant Melanoma

Following local invasion, MM frequently metastasizes and affects regional lymph nodes first, followed by hematogenous spread to lungs and liver in most cases

Clarks Level of Histologic Invasion In all MM, there is direct correlation between the level of histologic invasion and prognosis I In situ melanoma. Lesions with all tumor cells above the basement membrane II Neoplastic cells have invaded the papillary dermis but have not reached the reticular dermis III Entire papillary dermis is occupied by neoplastic cells which impinge upon but do not invade the reticular dermis IV Invasion of reticular dermis by neoplastic cells V Invasion has extended into the subcutaneous tissue Problem: where cut is made (you may have cut the lesion at higher, lower or tangential level, impairing reading of results) Diagnosis 1. Skin biopsy 3 to 5 mm patch 2. Evaluation of metastasis a. PE especially lymph nodes b. CBC with differential c. Liver profile check for metastasis d. Chest X-ray Treatment 1. Surgical excision with a 1 cm margin 2. Lymph node dissection (if palpable) prophylactic dissection not 3. Chemotherapy Dacarbazine, Interferon, Monoclonal antibody (MAb) or cellular immunotherapy Prognosis Depends on clinical type lentigo maligna better than nodular type Presence or absence of lymphadenopathy Histologic level of dermal invasion Without treatment progress to metastasis death If seen early and excised 80% cure If with visceral metastasis fatal Prognosis by Clarks o Level II 80-90% 5 year survival rate (excellent) o Level V survival rate drops to 2030%

Level III and IV intermediate figures

Tumor Thickness (Breslow Level) Thickness is measured from outermost layer of the stratum granulosum to the deepest penetration of the tumor in the dermis

melanoma allows early detection and treatment of this serious health problem Sometimes misdiagnosed, or patients are in denial

Course and Prognosis In general, the thinner the melanoma, the better the prognosis Localized disease has a far better prognosis than metastatic disease Female patients and younger patients tend to have a more favorable prognosis Melanoma on an extremity has a more favorable prognosis than on the trunk, head, and neck Melanoma on the scalp has a worse prognosis than melanoma elsewhere on the head and neck Some 85% of patients have stage I or II (local) disease Advice to Patients A. Seek prompt examination for the following: 1. All persons with family hx of melanoma 2. All persons with phenotypes I and II, especially those with a history in youth of intense sun exposure 3. All pigmented moles after puberty 4. All persons with many (uncountable) moles 5. Any changing mole in size, color, or border 6. Any mole that itches or is tender for more than 2 weeks 7. Any mole that is considered ugly because of its size, color, pattern, or borders B. Persons with phenotypes I and II should never sunbathe C. Sunscreens with SPF 30 or more should be used D. Avoid exposure to artificial forms of radiation (sunbeds and sunlamps) CAVEAT Full skin examination at regular intervals, especially of individuals at increased risk of