32 HOW TO TREAT : MELANOMA
32 HOW TO TREAT : MELANOMA
3 NOVEMBER 2023 ausdoc . com . au disease and those with stage IV metastatic disease . The availability of both immunotherapies and targeted therapies has provided exciting therapeutic options in the management of stage III and IV melanoma . Immunotherapies up-regulate the host immune response to be more effective against cancerous tissue . Molecular therapies target mutations in oncogenic molecular pathways in melanoma , such as mutations of the BRAF gene . 62
Multidisciplinary team management
It is recommended that patients with stage II or IV melanoma are cared for in a multidisciplinary team setting . Ideally , this would include surgical oncologists , medical oncologists and radiation oncologists .
PROGNOSIS
THE prognosis for melanoma varies , depending on the stage of disease progression . Surgical management alone may achieve a 10-year survival rate of 75-98 % in patients with stage I and II melanoma . 34 In contrast , patients with stage III melanoma who undergo surgical management alone have widely varying survival rates , with 10-year survival ranging from 24-88 %. 63 In patients with resected stage III disease , adjuvant radiotherapy greatly reduces local disease recurrence , though without significant survival benefit . 63 The outlook for patients with stage IV melanoma has improved with the advent of systemic immunotherapies and targeted therapies in recent years . Such therapies are now also being used in patients with resected stage III disease . 62
THE FUTURE
Neoadjuvant systemic therapies
THE promising outcomes produced by use of adjuvant immunotherapy and targeted molecular therapies in stage III and IV melanoma have raised questions regarding their possible benefit as neoadjuvant treatments , that is using systemic therapies as first-line treatment , followed by surgery . 64 Using this method , tumour response to systemic treatment can be assessed before surgery , providing important prognostic information to patients . 62
Skin lesion surveillance : Total body photography
Total body photography ensures precise documentation of the anatomical location and dermatoscopic features of lesions of interest . With serial imaging over time , the treating clinician can assess for important changes in specific lesions and detect the presence of new naevi . This process is a particularly beneficial screening tool for patients at high risk of melanoma because of a large number of atypical naevi .
CASE STUDIES
Case study one
JOHN , 67 , a retired electrician , presents to his GP for a full skin examination . He says his wife has noticed a new lesion on his arm . It has been present for a few months and is increasing in size .
He grew up on a farm in northern NSW and remembers having multiple peeling sunburns in his teenage years . He states his current sun protection is good — he wears a hat , sunglasses ,
Table 2 . Differential diagnoses of melanoma Lesion Atypical naevus
Blue naevus
Basal cell carcinoma
Defining features
Most atypical naevi can mimic melanoma All naevi with features concerning for melanoma should undergo excision after a thorough clinical and dermatoscopic examination 50
Clinical examination should reveal classic dark blue colour On dermatoscopy , there is structureless , homogeneous blue or blue / grey colour 51 History of the lesion being present from childhood is also supportive 51
The clinical and dermatoscopic appearance of basal cell carcinoma ( BCC ) varies according to subtype Pigmented BCCs may raise concern for melanoma because of areas of blue / grey pigmentation 52 In BCC , this pigmentation lacks a ‘ network pattern ’, and is often arranged in ‘ ovoid nests ’ or ‘ maple leaf structures ’ 52 On dermatoscopic examination , BCCs often display clear , in focus telangiectatic blood vessels 52 Ulceration is a common dermatoscopic finding in all BCC subtypes , and less common in melanoma 52
Dermatofibroma Clinically , a dermatofibroma should dimple on pinching the skin ; this is often referred to as the ‘ pinch sign ’ Dermatoscopically , a central white scar-like patch with peripheral pigment network is classic for dermatofibroma 53
Squamous cell carcinoma
Solar lentigo
Seborrhoeic keratosis
Squamous cell carcinoma tumours typically present as pink or skin-coloured nodules , and may have overlying scale or a central keratin plug Dermatoscopy of these lesions is characterised by scale , white circles and white structureless areas 54
Solar lentigo pigmented macules are typically well demarcated with a sharp border On dermatoscopy , a reticular or structureless brown network may be observed On the face , solar lentigo can be difficult to distinguish from lentigo maligna Features of asymmetrically pigmented follicular openings , rhomboidal structures or grey colour should raise suspicion for lentigo maligna 55
On clinical examination , seborrhoeic keratoses present as well-demarcated , pigmented patches that become raised and take on a waxy verrucous or ‘ stuck on ’ appearance over time Common dermatoscopic features include milia-like cysts , comedo-like openings and pigmented ridges 56
Figure 8 . Stitched wound after removal of a melanoma from the back .
Figure 9 . Lentigo maligna . sunscreen , and occasionally a longsleeved shirt . John has a personal history of non-melanoma skin cancers . He had 5-fluorouracil field treatment to his face several years ago and regularly has actinic keratoses treated with liquid nitrogen .
John drinks socially and is a nonsmoker . He has hypertension and hypercholesterolaemia that are both controlled with medication .
His younger sister had a melanoma a few years ago . She required only surgery and is doing well ; she has regular skin checks .
On examination , there is an irregular pigmented lesion with a nodule on John ’ s right upper arm . Dermatoscopically it has concerning features of a melanoma , including multiple colours in an asymmetrical arrangement , irregular border , and broadened pigment network ( see figure 11 ). There are no palpable lymph nodes in his right axilla . The remainder of the full skin examination is unremarkable .
The GP is concerned that this is a melanoma and as there is a palpable nodular component they arrange for an excisional biopsy with a 2mm margin . The biopsy is marked as ‘ urgent ’ and sent to the local histopathologist . Histology confirms a melanoma , a nodular subtype with a Breslow thickness of 1.8mm .
John and his wife attend the GP clinic four days later to review the wound and discuss the results . The GP gives John his diagnosis and provides him with written information on melanoma and the melanoma patient support information sites .
The GP refers John to a melanoma surgeon ( via the local public hospital ) for wide local excision and SLNB . The SLNB is positive and John ’ s case is reviewed at the local public hospital melanoma multidisciplinary team meeting . The medical oncologist starts John on immunotherapy ( nivolumab and ipilimumab ).
He has regular full skin examinations and reviews with his GP , dermatologist , medical oncologist and melanoma surgeon . John and his wife encourage their adult children to have a skin check .
Case study two
Amy , a 24-year-old schoolteacher , presents to her GP with concerns about a mole on the back of her right arm . She has many ( more than 100 ) naevi and was not previously aware of this lesion . Her partner noticed it was growing and darkening in colour and encouraged her to see a doctor .
Amy is well , with no significant past medical history . Her mother was diagnosed with her first melanoma in her early 30s . Amy ’ s grandmother and maternal uncle have also had melanoma .
The GP performs a full skin examination and notes the many atypical appearing naevi on Amy ’ s skin . Many of these are large ( greater than 5mm ) and appear suspicious based on the ABCDE criteria . However , the lesion on her right arm is an obvious ‘ ugly duckling ’ — it is much darker than her other naevi and , under the dermatoscope , the GP can see concerning dermatoscopic features of asymmetry and multiple colours . The clinical history of the lesion growing is also concerning .